Oireachtas Joint and Select Committees
Wednesday, 12 December 2018
Select Committee on Justice and Equality
Coroners (Amendment) Bill 2018: Committee Stage
As we are in public session, all mobile phones should be switched off as they cause interference, even if on silent mode, with the recording equipment in the committee rooms. Deputy Eamon Scanlon is deputising for Deputy Jim O'Callaghan.
This meeting has been convened for consideration of Committee Stage of the Coroners (Amendment) Bill 2018. I welcome again the Minister for Justice and Equality, Deputy Flanagan, and his officials. I extend a welcome to all our visitors in the Gallery. Does the Minister wish to make some opening remarks on the Bill before we go into the amendments?
I welcome that we are proceeding with this important legislation and I thank Deputies, and Deputy Clare Daly in particular, for their interest in the matter. As I informed the Dáil on Second Stage, subject to the advice of the Attorney General, I intend to bring forward a number of further amendments to the Bill. I am introducing a number of those today, including some new provisions that provide for the first time for an expressed jurisdiction for a coroner to inquire into a stillbirth where there is cause for concern. There is another provision for a coroner to direct a hospital or health institution where the deceased was treated immediately before death, or a doctor holding medical records of the deceased, to produce the records the coroner considers relevant and necessary for the conduct of an effective post mortem examination.
I also flag to the committee my intention, subject to Government approval, to introduce on Report Stage a number of further amendments upon which extensive work is already proceeding. I will come back to various further amendments during our discussion today as we proceed through the sections. I expect them to include, subject again to the advice of the Attorney General, a power for a coroner to seek directions from the High Court on a point of law regarding the exercise of the coroner's functions. There would be a section setting out governing principles for regulations to be made by me, with the agreement of my colleague, the Minister for Health, on proper and respectful storage and disposal of human organs or tissue retained for the purpose of an inquest or post mortem examination. There will be a number of amendments providing that in the small number of cases where the Garda Síochána Ombudsman Commission is investigating possible Garda involvement in a death under the Garda Síochána Act 2005, a designated officer of the Garda Síochána Ombudsman Commission may provide assistance to the coroner's inquiry or inquest.
I move amendment No. 1:
In page 6, line 29, to delete "previous existing" and substitute "pre-existing".
In accordance with the advice of the Office of the Parliamentary Counsel, this amendment makes a grammatical correction in the definition of indirect maternal death to refer not to a "previous existing disease" but, more correctly, a "pre-existing disease". Both terms are used in the World Health Organization, WHO, definition of indirect maternal death but the latter appears to be more grammatically correct. It also appears clearer. With this amendment the Bill will define an indirect maternal death as "the death of a woman resulting from a pre-existing disease or a disease that developed during pregnancy and which was not the result of direct obstetric causes but which was aggravated by the physiological effects of pregnancy".
The definitions of "maternal death", "direct maternal death" and "indirect maternal death" set out in the Bill are important new definitions in line with the internationally recognised World Health Organization international classification of diseases, ICD, definitions. They reflect the initiative on the part of Deputy Clare Daly to ensure the proper investigation of such deaths. The World Health Organization definitions are also those used by Irish doctors.
I assume the section will be agreed but I give notice of my intentions on Report Stage, when I may bring forward an amendment on proposals for the inclusion of further definitions in section 2. They may be necessary for the better functioning of the Bill.
It is a bit unfortunate that the Minister is talking about introducing amendments wholesale on Report Stage. There was the possibility of one amendment to be flagged for Report Stage in yesterday's discussions. The committee already scheduled a meeting for Committee Stage a number of weeks ago to try to conclude this Bill but that was postponed because the Minister indicated a wish to include a load of other amendments. We assumed those would be dealt with today but now we have references beginning to creep in for amendments we have not yet heard about. Given that the order for Second Stage of the Coroners Bill 2015 was moved by me exactly three years and one day ago, what is going on? It is grand if they are only minor amendments.
I am merely acting in accordance with Standing Orders of the Dáil. It is certainly my intention to limit the number of amendments tabled on Report Stage. There are a few which I intend to flag, but they will all be in accordance with accepted practice and procedure.
It is as clear as mud because the Minister did not answer the question raised. We have been waiting for this legislation for three years. We were supposed to have dealt with it on Committee Stage about three or four weeks ago. Now the Minister is talking about Report Stage as if the wheel had been reinvented because it was flagged nowhere and is against the wishes of the committee, all Members of the Dáil and the Minister's party members the length and breadth of the country. If he is telling me that there are only small issues and that we will take Report Stage in the first week or two after we come back in January, we can live with that, but what is he talking about?
Nothing I intend to introduce at any stage will in any way run contrary to the accepted Standing Orders of the Dáil or the committee. To provide further information which may help to alleviate the anxiety of Deputy Clare Daly, on publication of the Bill in August, I flagged that it was my intention to introduce amendments for consideration to increase the jurisdiction of coroners to inquire into stillbirths and give them the power to direct hospitals and health institutions to produce medical records of deceased persons for a post mortem. I am tabling the amendments today. I also flagged at the time of publication of the Bill for discussion on Report Stage the issue of a case stated and the power of a coroner to seek directions from the High Court on a point of law, with governing principles for making regulations for the treatment and disposal of human organs and tissue that might be retained for an inquest, something to which I referred in my opening comments. I intend to bring forward the amendment on Report Stage. I have also mentioned the issue of an amendment in respect of the Garda Síochána Ombudsman Commission.
It is not about that and I did not invite the people who are in the Visitors Gallery. They came on their own initiative because they are so concerned about the passage of the Bill and have direct involvement in its progress and because we have been at the edge so many times before. All I was trying to do was seek clarity from the Minister on whether this amounted to another delay or whether they were just small technical issues that would be sorted out. However, I am none the wiser, but we will leave it for now and complete Committee Stage because ultimately it is the Dáil that will decide.
Perhaps the most important issue is that of the Minister being able to indicate that Report and Final Stages of the Bill will be taken at the earliest possible date after the completion of Committee Stage. I hope that is his intention.
I move amendment No. 2:
In page 7, between lines 36 and 37, to insert the following:
“Application of Act to stillbirths
3.The Principal Act is amended by the insertion of the following section after section 2:“2A.(1) This Act, other than sections 17, 18, 33A and 40, shall, where the context so requires, apply to a stillborn child in the same manner as it applies to a deceased person subject to the modification that the provisions in subsections (2) to (5) shall apply to a stillborn child instead of sections 17, 18 and 33A, and any other necessary modifications.
(2) Where a coroner is informed that the body of a stillborn child is lying within his or her district and that a medical certificate stating that the cause of death due to a natural cause or causes is not procurable, he or she may inquire into the circumstances of the death of the stillborn child and direct that a post-mortem examination of the body of the stillborn child be made under this Act and, if he or she is unable to ascertain the cause of death, may, if he or she so thinks proper, hold an inquest in relation to the death.
(3) A coroner may, for the purposes of performing his or her functions under subsection (2), have regard to any of the following circumstances in so far as they applied, or may have applied, to the mother of the stillborn child concerned and the likelihood that they may have caused or contributed to the death of the stillborn child:(a) violence affecting the mother of the stillborn child at the time of the death, or immediately before the death, of the stillborn child;(4) When deciding under subsection (2) whether to hold an inquest in relation to the death of a stillborn child, a coroner shall—
(b) the mother of the stillborn child was in State custody or detention at the time of the death, or immediately before the death, of the stillborn child;
(c) the mother of the stillborn child was involved in an accident at work or was affected by an industrial or occupational injury or disease or industrial poisoning at the time of the death, or immediately before the death, of the stillborn child;
(d) the death of the mother occurred unexpectedly and from unknown causes or in an unexplained manner;
(e) the death of the mother was a maternal death or a late maternal death;
(f) the death of the mother occurred in circumstances which, under provisions in that behalf in any other enactment, require that an inquest in relation to her death should be held.(a) have regard to the matters referred to in subsection (5), and(5) The matters to which a coroner shall have regard for the purposes of subsection (4) include the following:
(b) if it is practicable to do so, consult with a family member of the stillborn child.(a) whether the death of the stillborn child concerned has been reported to the coroner in accordance with section 16A;
(b) whether, upon inquiry by the coroner into the death, sufficient information in respect of the death of the stillborn child concerned has been provided to the coroner;
(c) whether a post-mortem examination of the body of the stillborn child concerned has been made under this Act and the report of that examination;
(d) the views (if any) of a family member of the stillborn child concerned furnished to the coroner in writing as to whether the death was a natural one.”.”.
This is an important amendment which for the first time provides an express statutory power for a coroner to inquire into the death of a stillborn child. The Bill defines a stillborn child in section 2 as "a child of not less than 24 weeks’ gestation, or of birth weight of not less than 500 grammes, who is delivered without signs of life". This is the accepted medical definition in Ireland. It is also the definition used in the Civil Registration Act 2004, section 30 of which requires a stillbirth to be reported in the register of deaths as soon as is practicable. This is a mandatory reporting requirement applied to the doctor, the midwife and the head of the hospital concerned. The Civil Registration Act 2004 also provides in section 28 for the optional reporting of the stillbirth by the family and the issue of a special stillbirth certificate, if they so request. The Coroners (Amendment) Bill 2018 now also requires mandatory reporting of stillbirths to a coroner. Point 18 in the new schedule of reportable deaths specifies that any stillbirth must be reported to the coroner. Section 6 of the Bill inserts a new section 16B(4) into the principal Act and provides for mandatory reporting of a stillbirth by the doctor, nurse or midwife who is responsible for the care of the mother. The Coroner Service website lists certain stillbirths as reportable to the coroner as a matter of good practice and stillbirths are regularly reported to coroners by the doctors involved. Coroners indicate that the large majority of stillbirths reported to them are natural and expected spontaneous stillbirths and are certified as such to the coroner's satisfaction by the mother's doctor.
In a very small number of cases there are circumstances surrounding the stillbirth such as concerns about possible medical errors, for example, which give rise to concern. Coroners are very conscious of the sensitivity of such cases in practice and further inquiry is rare. It is typically where the bereaved parents request it. However, the mandatory reporting requirement introduced in the Bill will address the public concerns I have mentioned and support independent oversight and transparent investigation in the small number of cases where concerns arise.
The amendment I have brought forward complements the reporting requirements in the Bill by providing a discretionary power for a coroner to inquire into a stillbirth and, if the cause of death remains unclear, to direct a post mortem examination and, as appropriate, the holding of an inquest. There are two special features. While reporting a stillbirth to the coroner is mandatory, the coroner's inquiry and any post mortem and inquest into a stillbirth will be at the discretion of the coroner, subject to the criteria set out in the new section 2A, sections 17, 33A and 40 of the Bill which provide, respectively, for a mandatory inquest in certain cases, a mandatory post mortem in certain cases and mandatory juries in some cases, which are expressly disapplied to stillbirths. In exercising his or her discretion the coroner must consult a family member of the stillborn child if it is practical to do so. He or she must have regard to their views in deciding whether to hold an inquest. The provisions recognise the particular sensitivity of these cases and the very diverse circumstances that can arise.
The amendment is also a response to the advice from the Office of the Attorney General that a coroner's powers to inquire into a stillbirth should be clarified. This arises because the Coroners Act 1962 refers to a coroner inquiry into the death of a person. This phrase is interpreted in Ireland and similar coronial legislation in England and Wales as referring to a person who was born alive, took independent breath and subsequently died but excluding a stillborn child who never drew what can be described as independent breath. In practice, however, media reports indicate a small number of cases in recent years in which coroners have held a full inquest into a stillbirth, typically at the request of bereaved parents.
The question of extending the coroner's jurisdiction to stillbirths is also being examined across the water in England and Wales, as well as in Australia, but remains in early stages in both jurisdictions. The proposal was welcomed in the UK by the Royal College of Pathologists and by UK organisations that advocate for patient safety and transparency in the context of stillbirths and neonatal deaths.
Conversely, coroners in Northern Ireland can inquire into a stillbirth since a judgment of the Northern Ireland Court of Appeal in 2013 held that the coroners have jurisdiction under a Northern Ireland statute of 1959 to hold an inquest into the death in uteroof a child who was capable of being born alive. The fact that this is a new question for other common law jurisdictions makes it prudent for us to adopt a discretionary approach, at least initially.
The proposed subsection (3) sets out circumstances which may be taken into account by the coroner inquiring into a stillbirth where the cause of death remains unknown. Any of these circumstances, if applicable to the death of the mother, would give rise to a mandatory post mortem and inquest under sections 17 and 33A of the principal Act inserted by the Bill. As sections 17 and 33A are disapplied to stillbirths, these relevant circumstances are set out in section 2A(3) simply to clarify that a coroner can still take them into account when exercising his or her discretionary powers.
This was an amendment the Government flagged to us earlier and I am sure we all will welcome it because where there is any question about the reasons for a baby dying, either during labour or otherwise, those questions need to be answered, not just for the family but also for the health service. As the Minister said, while the section is not providing for mandatory inquests into baby deaths, it does provide that they will be reportable and that other provisions of the Act will apply, such as the coroner being empowered to compel the handover of records and so on. I certainly hope that although the power is discretionary, its inclusion in this Bill will bring us to a safer position in our hospitals in circumstances like those suffered by the Reilly family, for example. The investigation into the death of their baby, Asha, took place a full 11 years after she died, thanks to the most appalling actions on the part of Portiuncula Hospital. I hope these measures will prevent that happening again.
It is important to put the importance of this legislation on the record. We constantly hear about the excellent quality of our maternity services but between 2007 and 2017, there were 31 inquests into baby deaths in the Republic of Ireland. In June 2016, the investigation of baby deaths in Portiuncula Hospital was only one of many. Seven out of the 19 maternity units at that time were either under independent investigation or involved in inquests. It is a very big issue and we need to learn the lessons.
The added trauma parents have to endure following the death of a baby, as we saw in hospitals like Portlaoise and Portiuncula, due to the stonewalling by hospitals is abhorrent. We know from the sample of 30 baby deaths due to negligence in Irish hospitals between 2008 and 2016 that in every single case where there is a record of an apology or a settlement, it was received three to nine years after the baby had died. In many instances there was a settlement with no admission of liability and no apology. The parents are on the record as describing the added trauma that caused to them.
I will not make those points again but it is a thread on this legislation that people deserve answers. It improves our health service and if one wants to be cynical about it, it potentially saves the State tens of millions of euro every year in legal fees. We have to move to a situation where we give people the information, tell them what they need to know and improve our services. The amendment is very important and I welcome it.
I thank Deputy Clare Daly for her comments and apparent agreement on the matter of the mandatory reporting and, as a consequence, the discretionary power on the part of the coroner. Having regard to developments, both in this jurisdiction and across common law jurisdictions, I repeat that it is prudent for us to adopt the discretionary approach contained in the amendment.
Amendment No. 3 in the name of Deputy O'Callaghan has been deemed to be out of order, representing a potential charge on the Revenue, which is always unfortunate because members have validly considered the merit of the proposition. Having it deemed out of order on that basis is most unfortunate.
I move amendment No. 4:
In page 11, line 8, to delete “prior to” and substitute “before”.
These are technical drafting amendments to section 6 and I ask that they be treated accordingly. Section 6 provides for a more strengthened regime for the reporting of certain deaths to the coroner. It inserts new sections 16A and 16B in the principal Act. Section 16A sets out an expanded and clarified list of the types of death which must be reported to the coroner, while section 16B sets out an expanded and clarified list of responsible persons who are required to report such a death to the coroner. Accordingly, amendment No. 4, which proposes to delete "prior to" and substitute “before” on page 11, line 8, is a technical drafting amendment. This was suggested by the Office of the Parliamentary Counsel to ensure consistency. Section 16B(3)(h), as amended, will provide that a person who had care of the deceased person immediately before his or her death is required to report the death to the coroner if it is a reportable death for the purposes of section 16A.
While amendment No. 5 may be technical, it is important. The amendment provides for an additional category of persons who are responsible under the new section 16B(3) for reporting a death to the coroner. It refers to those who were responsible for a person while he or she was in State custody or detention immediately before his or her death. It would apply, for example, to the governor of a prison.
Amendments Nos. 6 and 7 are purely technical, providing for the re-lettering of the remaining paragraphs in new section 16B(3) of the principal Act, as inserted by section 6 of the Bill. The re-lettering is needed following the insertion of the new paragraph 16B(3)(i), as discussed under amendment No. 5.
I wish to comment on amendment No. 5. The Minister was clarifying the exact responsibility and how it is defined. The Minister is saying the Governor would be tasked with reporting the matter rather than the individual. For example, if a prison warden is the first to find out about a death, the onus falls to the Governor. Is that right?
It is whoever had responsibility for the deceased person. I think these amendments are technical in nature and I do not believe there should be any issue with them. In the absence of any other comment I will dispose of each of them.
I move amendment No. 5:
In page 11, between lines 9 and 10, to insert the following:“(i) where the deceased person was in State custody or detention immediately before his or her death, a person who, pursuant to an enactment or otherwise, had responsibility for the deceased person;”.
I move amendment No. 8:
In page 12, to delete lines 19 to 25 and substitute the following:“(3) At the request in writing of a family member of the woman concerned, a coroner may decide not to hold an inquest in relation to the death of a woman that is a maternal death or a late maternal death, if, having regard to the matters referred to in subsection (4), the coroner is satisfied that the death of the woman is a natural one and, therefore, an inquest in relation to the death is not necessary.”.
This is the substantive section of today's discussion in many ways and we will take some time on it because it is the meat in the sandwich. This relates to mandatory inquests for maternal deaths. The measure will have a triple effect when it is implemented. It will give families the fullest picture about the train of events that led to the death of a loved one. It will give clinicians and the HSE a crucial insight into where the system is failing women. Finally, it will give us, as policymakers and those holding the purse strings, the information to make our services safer.
This is critical, and the reason I was a little stressed in asking about the amendments on Report Stage was that I was mindful that several of the people in the Gallery today, including midwives and husbands who have lost their wives, were here three years ago looking for this legislation. Three years on, we know that a number of other women have lost their lives in our maternity services. This is beyond urgent. I say as much in recognition that this is where the tetchiness came from. I have no wish to see Report Stage delayed. Having said that, I want to be absolutely clear that we are in a completely different place now to where we were three years ago. We are on the verge of delivering this legislation - there is no question or doubt about that.
This is the amendment we are really pushing. I want to explain why because the reason gets to the heart of much of what we are talking about. The World Health Organization estimates that between 88% and 98% of all maternal deaths are preventable. That is shocking. It means they should not or did not need to happen. Obviously, every one of these cases is a tragedy.
We need as much information as possible delivered through inquests into maternal deaths to make our services safer. Let us consider the case of the death of Tania McCabe in March 2007. The inquest found that Tania and her son Zach had died as a result of septicaemia and returned a verdict of medical misadventure. As a result, the HSE created guidelines on the management of septicaemia, something that should have been implemented in all maternity units. Of course, we found out some years later at the inquest into the death of Savita Halappanavar that only five of the 19 maternity hospitals or units had implemented those guidelines. In other words, without the inquest into the original death or the latter case we would not have had the guidelines or found out about their non-implementation. The inquests were critical in developing the services.
I will set out some detail on this specific amendment to the Bill. What we are trying to do is make it absolutely and crystal clear that a decision by the coroner to not hold an inquest – we are talking about mandatory inquests into maternal deaths – will only be taken after a family member has asked for that decision and provided the coroner is satisfied, on the basis of the post mortem and other information available, that the death of the woman was natural.
This question arose three years ago on Second Stage. This was the major issue. The relevant Minister at the time, Deputy Harris, said that we did not want the unintended consequence of a bereaved family having to go through an inquest where the causes were obvious and the family did not need an inquest. The reasoning was that there may have been a pre-existing cancer or something like that and there may have been no dispute about it. The idea was that no one would want to re-traumatise people in cases of a tragic but natural death, as it were, or force the family to go through an inquest.
We have been trying to strike a balance between the needs of the family and the wider public interest. We have to be absolutely sure that we avoid a situation under this section whereby deaths that are avoidable do not get the inquest they should. We believe the way the Government has framed the legislation at the moment gives a little too much latitude to the coroner. It is a little too broad for us to be entirely comfortable with it at this stage. We would prefer a situation whereby it would only be possible for a coroner to decline to hold an inquest if specifically asked not to in writing by a family member as well as being satisfied, on the basis of the information available, including the post mortem, that the death was natural. The provision is not strong enough at the moment.
The issue for us is not that we believe the coroners will be declining inquests left, right and centre. We do not believe that to be the case – I am keen to put that on the record. I fully accept that these instances will only arise in exceptional cases. However, it is still important because the concern boils down to the fact that whether a maternal death is natural or otherwise is not always obvious. We need to be clear on that point.
Maternal healthcare is getting more complex. Our knowledge of what amounts to maternal death and natural death is changing. There has been a fall in direct maternal deaths, which is to be welcomed. It is probably as a result of improvements in our health service. However, the number of indirect maternal deaths has increased due to issues like obesity and diabetes, which are now major problems in Irish society and in many other European countries as well. Clinicians and coroners are faced with what one researcher called increasingly intricate associations between underlying medical and pregnancy-related pathology. Now more than ever it is likely that a death that looks natural and as if it has nothing to do with a pregnancy might actually be a maternal death. That is the issue we are trying to get to the heart of with this amendment. It is about changing and understanding the links between these complex medical factors. The coroner might not actually be up to speed about the nature of these changes. A coroner might think, entirely innocently, that a death is natural, for example, because of a heart attack. The coroner may believe it is clear that the woman died of a heart attack and so the death was natural and could have happened to anyone.
The reality is that an aneurysm that was made more likely by pregnancy could have been avoided and the right medical pregnancy treatment might have altered the situation. This is what we are trying to get at.
The window of discretion available to a coroner not to hold an inquest should be closed little further. This should only be an option if a family specifically requests it. We should put on the record, because in some ways this is where it started, that what we want to avoid is a worst-case scenario whereby it is less a case of intricate associations and is about more obvious ones. I will use the example of the death of Bimbo Onanuga who died in March 2010. On the basis of a perfectly written and perfectly correct post mortem report submitted to the coroner's office, the coroner first ruled there was no need for an inquest into her death as he deemed it was one of natural causes. Subsequent queries by international experts centred on what lay behind the rupturing of her uterus and what was the train of events that led to that moment. When the coroner was subsequently presented with the queries and granted an inquest he asked for 19 depositions and witnesses from the hospital concerned and, ultimately, there was a verdict of medical misadventure. The point here is that initially the coroner was satisfied it was natural causes on the basis of the post mortem but this subsequently turned out not to be the case. This is what we are trying to do here.
I recognise that once the Bill becomes law there will be a very strong positive obligation on a coroner to hold an inquest, which was not the case previously. I realise fully that for a coroner to take a step to decline an inquest when the Bill is law would be much more serious than before and there will not be a huge amount of wriggle room but the concern remains that if it is a coroner who starts the process of exercising discretion regarding to whether to hold an inquest the whole point of a discretionary element to make things better for bereaved families will be lost and an inquest that perhaps should take place will not. This is the impetus behind the amendment. We feel strongly about it. We do not think it is huge. All it does is tie the hands of coroners a little tighter so that matters are cut and dried and the families are respected but the health service gets the information it needs.
I want to mention in the first instance the point raised by Deputy Clare Daly on the timeframe and acknowledge on the part of the Government the urgency here as well as the importance. I would be very keen, if we complete Committee Stage today, that we would be ready for Report Stage early next term. Not by way of any reason or excuse for any perceived delay, I acknowledge that many of the people working on the amendments to the legislation and engaging with Deputy Clare Daly and others on the committee are also very much involved in the termination of pregnancy legislation. It may well be reasonable to assume that Bill will be enacted by the end of this year. I assure the committee there will be no delay in proceeding to Report Stage. The intention is that we will be in a position to seek a date with the committee by the end of the first month of next year. I know the urgency on the part of the committee. It is one that is shared by me in the context of issues that have been raised.
On the matter of the amendment, which is important, I want to stress that under the provision I have proposed there are three tests in which the coroner needs to engage. These are consultation with a family member of the deceased woman having due regard to the matters listed in subsection (4), including, of course, the views of the family members of the deceased woman, which is the point raised by Deputy Clare Daly, as to whether the death was natural; the result of any post mortem examination; and that the coroner needs to be satisfied that the death was natural and that an inquest is, therefore, in the circumstances not necessary. If all of these tests are satisfied the coroner has the decision-making capacity on whether to hold an inquest. It is after due and careful consideration.
Deputy Clare Daly really got to the nub of the argument when she mentioned tying the hands of coroners. It is important that we recognise the independent and official capacity of coroners. My concern with regard to the amendment is that we could well tie the hands of a coroner who, irrespective of any considerations, would have to inquest every late maternal death unless a family member of the deceased requested otherwise in writing. I see this as being, in many respects, unduly restrictive of the independent role coroners have in law. I am also of the view that the amendment would create a further issue in that, effectively, the action or inaction of a single family member could exercise a greater level of authority than might in the circumstances be necessary, where an individual family member may be in a position to decide unilaterally whether an exception, which is provided for reasons of public policy, would apply to a maternal death.
While I have some sympathy for the point raised by Deputy Clare Daly in her amendment, my view is that a coroner would be inclined to hold an inquest in any event if a death is clearly unnatural and even if it in a case where it may be unnatural. We have to look at the long-standing approaches that have been taken by coroners under the existing legislation, section 17 of which requires that it shall be the duty of the coroner to hold an inquest into a death if the coroner is of the opinion the death may have occurred in an unnatural or violent manner. I stress that in arriving at a decision a coroner is required to have regard to all of the evidence, with specific reference to the proposed section 7(3) on the results of the post mortem, the views of a family member and whether sufficient information was made available at the time. In practice coroners attach considerable importance to the views of the family, and rightly so.
I also note that Deputy Clare Daly's amendment would remove the statutory obligation under section 7(3) that would require a coroner to engage in active consultation with a family member. It is important to acknowledge there may be circumstances where family members might disagree with each other. Often, an individual family member might take a different view from other members of the family.
When such circumstances arise, it is important to acknowledge that, as a matter of general public policy, a coroner acts as an independent public official and never in any capacity as a private individual or in circumstances where there might any connection, perceived or otherwise, to the deceased. It is the coroner who makes the final decision on whether a death that may appear natural should be, in the public interest, the subject of an inquest. That is a fundamental principle of the system and I would be concerned if we moved towards weakening or changing that in a way that might be perceived as being compromised. There is no precedent for making an exception to this principle.
I acknowledge, with sympathy, the point raised by Deputy Clare Daly but I also wish to stress the independent role and function of coroners and the long-standing practice of coroners in any event, as well as the mandatory obligation there will be in respect of consultation.
We are trying to do the same thing as the Government only in a different way. The Government's wording creates the possibility that a coroner could go against the family's wishes and decide not to hold an inquest, but that would not be possible with our wording. Equally, the Government's wording creates a situation where it is possible for the coroner to start the ball rolling in terms of having a discussion about not having an inquest, but the goal here, as the Minister said on Second Stage, is to avoid a situation where a bereaved family might find itself having to participate in an inquest which it might not wish for in certain circumstances, and that it is not to give coroners a route out of holding maternal death inquests. However, that is an unintended consequence of how the Government has drafted the Bill. With our wording, only the family can precipitate any conversation about not having an inquest.
A final consequence of the Government's wording is that it leaves too wide a gap through which deaths that appear to be natural but are not could slip, meaning inquests that should be held are not held. If the goal is to protect bereaved families from having to go through a process which, on the basis of the all the facts of the case, is not necessary, our wording achieves that while the Government's does not. We are trying to put safeguards in place for women. Let us ensure we do that and leave no space for it not to happen.
That sums it up very well. The point is that the legislation ties their hands. We are instructing coroners to hold a mandatory inquest in cases of maternal death. The only exception that has emerged is in cases where it would not be necessary, where the reason was obvious and clear and we do not wish to traumatise the family again. That was the only exception we all wanted. As Deputy Wallace stated, our amendment allows us to do that, but the Minister's does not. His amendment permits a scenario, albeit that it might not happen very often, with the possibility of a coroner deciding not to hold an inquest in a case where one should be held. Maternal deaths are different. We are talking about otherwise healthy people interfacing with the medical system or maternal care and ending up dead. It is a major issue. The examination of the underlying events that led up to that is immensely important. I again make the point that what might appear natural to a coroner in the post mortem or in the report from the hospital might not be, due to underlying issues, and we are losing valuable information there if our amendment is not accepted.
I accept the point about consultation. We are not opposed to tidying that up on Report Stage. Obviously, the family's decision not to have one should be following consultation with the coroner. That is accepted. At the same time, however, it should be the family's decision, not the coroner's. That is the purpose of the Bill and what we are trying to achieve.
The current wording, "whenever he or she so thinks proper", is quite open-ended in terms of discretion. It is too open-ended for what Deputies Clare Daly and Wallace are trying to achieve with their amendment. The Minister's amendment which proposes to insert "if any" after "views" removes the focus on the engagement with family members. He is inserting an ability for the coroner perhaps to opt out of the level of consultation the Minister aspires to in his words. Why is he inserting "if any" after "views" in section 7(4)(d)? Would it not be better to leave the existing wording?
I had intended to comment on that point. I agree with it. I had intended to say that but I forgot. If our amendment is passed this amendment would be redundant but if our amendment is not passed I will definitely oppose the Minister's amendment, precisely because of the point Deputy Jack Chambers made. The spirit of this section was supposed to be a coroner exercising discretion to spare the feelings of a bereaved family. This stands all that on its head. The coroner can do it even without the wish of the family.
I wish to add a further comment before the Minister responds. I appreciate the difference in the two positions. The amendment proposed by Deputies Clare Daly and Wallace states, "At the request in writing of a family member of the woman concerned, a coroner may decide not to hold an inquest". There still is a degree of determination on the part of the coroner who "may decide not to hold an inquest" or who could proceed to hold the inquest. I have followed the issue of maternal deaths and the need for mandatory inquests and this moves it positively towards the mandatory position. The wording of the Bill leaves a degree of flexibility and independent action on the part of the coroner. Like Deputy Clare Daly, we would all be of the view that this, please God, will be very rarely employed, and it would be preferable that it would not have to be employed at all. Where it does present there is consultation with a family member, but when one looks at the definitions in that regard there might not be a representative view that is a unanimous view of all concerned. According to what is stated on page 6 of the Bill, the coroner could speak to "a parent, grandparent, child, brother, sister, nephew, niece, uncle or aunt, whether of the whole blood, of the half blood or by affinity, of the person". That is very wide; it is not specific. One could have a consultation and in that situation many others might feel that their views were not properly reflected. In the other situation, at the request in writing of a family member not to hold an inquest the coroner may decide and could proceed to hold an inquest. On balance, given the history of this and the genesis of the thinking behind it, amendment No. 8 is the more appropriate reflection of public thinking on this issue at this time.
I think amendment No. 8 is a more appropriate reflection of public thinking on this issue. I just offer that further observation and invite the Minister to respond to our collective views.
Without repeating the points raised earlier, under section 17(4) there will still be a provision for the coroner to take account of any written views that may be submitted by the family. While that section does not provide for an obligation on the part of the coroner to consult with family, this is provided for in section 17(3), which Deputy Clare Daly proposes to replace. That could be problematic. I would ask the Deputy to reflect between now and Report Stage on how we might best meet the concern as adverted to by the Chair. I do not think there is much between us in terms of what we wish to see enshrined in our legislation but I do not want to be accepting amendments that will have unintended consequences. There are a number of drafting issues to which I made reference earlier.
Reference has been made by Deputies to a number of deaths, some of which took place many years ago. I want to acknowledge that coroners are very well aware of issues and of the significance of maternal deaths. They are well minded to hold inquests in such cases. Coroners experience regular briefings on the latest research and development. They have a technical understanding of issues to hand that may be developing in accordance with updated and modern research. We can expect that to continue to intensify further as this legislation is passed. I ask Deputy Clare Daly not to press the amendment but to see how we can reflect over the course of the Christmas vacation on reaching a meeting of minds. I must acknowledge the independent legal role of coroners in our public service. Coroners are not directly connected with any matters of substance that may appear to be the subject matter of decision.
I can understand the Minister's concerns but the Bill was drafted to ensure that where there are maternal deaths, an inquest is held. That is my understanding of the Bill. I am aware of maternal deaths in my own locality where the husband, as it was in those cases, had to fight tooth and nail to have an inquest held. I am aware of two cases where it took some time and a lot of persuasion to ensure that the inquest was held. Deputy Clare Daly's amendment is reasonable in the sense that people will not have to go through that trauma to make sure that an inquest is held. As it stands, the coroner has the option based on the autopsy to decide whether or not to have an inquest. I agree with the other members that it is a bit loose and needs to be tightened up.
Deputy Scanlon's is totally correct. The Minister talks about the independent legal role of the coroner and that is absolutely and totally accepted. While acknowledging that, however, we have of course already got legislation placing a mandatory requirement on them to carry out inquests in a number of cases. We are just adding maternal deaths to that category for all of the reasons Deputy Scanlon highlighted. The only objection was that we do not want inadvertently to damage or harm bereaved families. That is the purpose of this opt-out clause. The very reason this legislation is tabled and the reason there is a bit more awareness of it among coroners is that it was precisely the families who led the battle to get this information. It would be incredibly unusual for a family not to want to get the answers. These are instances in which the partner or family may have been present and may have a difference with the hospital. The hospital could be saying everything is grand and there is nothing to see here. However, the partner or family members who were there with the woman may have seen a sequence of events for which they want answers. Families want answers and we should not be afraid of that. Our amendment provides a better balance; this is about mandatory inquests. We can look at tweaking the consultation part on Report Stage but I will be pressing it now. If the Minister wants to reflect on it over Christmas, by all means, he may do so, but I am happier to go with our wording now. If the Minister wants to come back with something different in respect of the consultation issue on Report Stage, that is fine. It is critical that we move on this now.
Before the Minister responds, there was one related matter about which I am anxious. Where an inquest has been denied and it is very definitely the view of the bereaved that an inquest is important and necessary, the process for appeal, as I understand it, currently takes place through the Attorney General. Can the Minister clarify whether that is the case? I have a sense that this merits serious reconsideration. Let there be no mistake; the Attorney General is a politically vulnerable individual who sits at the Cabinet table and is open to the vagaries of the political system. That office or officeholder does not strike me as being independent in every respect. Has any consideration been given to this matter in the drafting of the Bill? If not, I reserve the right, as the Minister has done, to bring forward an amendment on Report Stage if colleagues feel it is appropriate to do so. I would appreciate whatever light the Minister can shine on that matter.
In response to Deputy Clare Daly, I am not sure if the reflection to which she refers will involve her refraining from pressing the amendment now in order to see how best we can accommodate the view that she has expressed in the amendment. If she decides to press the amendment with the support of the members, my concern is that, regardless of whether it is intended, it will have one serious consequence. That is that it would remove the statutory obligation under section 17(3) for the coroner to consult with a family member of the deceased woman. I would be concerned if we are now to insert amendments without the type of reflection that I believe is both appropriate and necessary.
Under the current provision, there is a clear obligation on the coroner to consult, have regard to and be satisfied before making a decision. These thresholds are in-built in the legislation and can adequately deal with the circumstances as outlined. I am prepared to look further to see whether we can reach a meeting of minds on this matter, but I am concerned by a number of weaknesses in the amendment. If the committee was minded to accept it in its entirety, I would have to caution against that.
Regarding the Chairman's question, there is not an appeal. It is an application to the Attorney General to direct that an inquest take place. Notwithstanding this legislation, there is something of a major re-organisation of the coroner system. Members will be familiar with the Bill of some years ago. Enshrined in that proposed Bill was a plan for a chief coroner to examine the matter of appeals. This is an issue on which work continues. It would involve significant organisational restructuring, but it is an issue that is receiving consideration.
The Chairman will be aware that there is a provision whereby a decision of a coroner can be subjected to a judicial review. That is in addition to the application that can be made to the Attorney General.
I thank the Minister for that. It is an appeal - that is how we lay people would view it in any event, and the Minister used that language in his concluding sentences. The Attorney General can direct a coroner or, actually, override a coroner's previous decision not to proceed. In preparing for today's meeting and informing myself of the methodology, I was alarmed to see that this was the recourse that people had. I do not believe that anyone who works in this institution would be in any doubt that the Attorney General is hardly an independent arbiter in such a situation.
The Minister has overly complicated the consultation issue in a manner that is not necessary. The element that we removed, and which can easily be put back in, referred only to instances where the family would be consulted before any decision on not proceeding was taken. However, that removal has to be seen in the context of what we are including, that being, a requirement that the inquest can only not go ahead if the family initiate that decision and write to the coroner. There is no question of the family's wishes being diluted by our proposition in its entirety. We are reflecting fully the family's wishes. However, I accept that, prior to the family making that decision, it would be better if the family had a chat with the coroner and aired those views in an holistic way. That is not a big deal and can be added to the Bill later by the Minister. It is not that we are taking out a family's right to consultation or involvement. Rather, the purpose of the amendment in its entirety is to put the family's wishes centre stage.
All of this comes back to our point that the coroner already has discretion under this legislation. We are making it mandatory. This is a tiny exception that we do not want to be blown apart, putting us back to where we were in the beginning. I just wanted to clarify the point.
It is important that we not read the amendment in isolation given a weakness in inserting it where Deputy Clare Daly has proposed. We acknowledge that a coroner must, under the Bill, have regard to all of the facts listed in the proposed section 17(4), must be satisfied that the death was a natural one and must be satisfied that an inquest is unnecessary. Even if all of those tests are satisfied, though, it appears that a coroner cannot decide not to hold an inquest unless a family member asks him or her in writing. For example, if the deceased woman has no identified family members or if there are no family members who contacted the coroner involved in writing, it seems in these circumstances that the coroner must hold an inquest even if there is clear evidence that the death was natural. I am concerned that Deputy Clare Daly's amendment - I accept that she may not have intended this - appears to tie the hands of the coroner who, irrespective of any other consideration, would be obliged to have an inquest unless a family member requested otherwise. Under the amendment, that request must be in writing. I would ask that this issue be reflected on. I would offer assistance in reaching a position that could gain favourable consideration across the board.
There is no point in us going around in circles. I want to put this to a vote. The purpose is mandatory inquests. If the case is that straightforward, the inquest will not be too taxing, so I would not worry that much about it.
I move amendment No. 10:
In page 12, after line 38, to insert the following:“(2) The amendments of section 17 of the Principal Act effected by subsection (1)shall apply to the duty of a coroner to hold an inquest in relation to the death of a person that occurred before the commencement of this section only if, upon that commencement, the inquiries of the coroner into the circumstances of the death have not been completed and he or she has not decided whether to hold an inquest in relation to the death.”.
Amendment No. 10 deals with the transitional application of the changes introduced by this Bill. Certainly, it is my view that the most straightforward approach, legally, would be to provide that changes made by the Bill apply only to deaths occurring after the commencement of the legislation. However, there is a preference for a broader approach.
My amendment limits the application, only, of the changes made by section 7 of the Bill to section 17 of the principal Act dealing with mandatory inquests. It allows application, even of those provisions, to deaths occurring before the commencement of the Bill if, on commencement date, the coroner has not yet completed his or her inquiries into the death and has not yet decided whether to hold an inquest. Having consulted with the Office of the Attorney General, and having consulted with coroners, it appears that legal complications and legal uncertainty would be likely to arise if the Bill were applied to pre-commencement deaths, in respect of which the coroners had completed their inquiries and perhaps even held an inquest.
Having regard to the large numbers of natural deaths occurring in different types of State custody, such as in detention, it appears from consultation with coroners that requests to reopen such cases with a mandatory inquest now could give rise to a very significant consequence in the coroner system.
I acknowledge what the Minister is trying to do. The amendment provides that the duty to hold an inquest into maternal death and a death in State custody does not have retrospective effect. This prevents the State from having to investigate the deaths of everyone who died in prison of old age, for example, but I would like to hear more about the position on maternal deaths. It is worth having a conversation on whether the provision could work in tandem with some other route for people who have been denied an inquest up to now, or who will have been prior to the enactment of this legislation. We are aware of a death that occurred a number of years ago in respect of which the husband of the woman had never been granted or had never sought an inquest. That process is now under way, however. Is there some route for such people? We envisage something other than a formal appeals process or something else in order that families who are currently unhappy about a coroner's decision not to hold an inquest would have a route under this legislation to have their cases re-examined without giving rise to the Minister's problem of retrospective application in all cases. Could something be built in on Report Stage in this regard? It might be worth considering. I am not opposing the amendment.
I would be happy to do that, having regard to the fact that maternal deaths in institutions or places of custodial detention are very rare. We are talking about young women. I am keen to pursue the point raised by Deputy Clare Daly and I will obtain some figures. I ask members to acknowledge that we are dealing with circumstances that are very rare. I shall have regard to the valid point made by the Deputy.
I intend to introduce an amendment to section 20 of the principal Act on Report Stage with the intention of permitting a designating officer of the Garda Síochána Ombudsman Commission, GSOC, to act in circumstances where the Garda cannot to assist a coroner and to amend the current provision for an inspector of the Garda to request a coroner from an adjoining district to hold an inquest by providing instead that it would be for the Minister to direct a coroner or deputy coroner in this regard. I will have the amendments available as soon as possible.
I move amendment No. 12:
In page 17, between lines 31 and 32, to insert the following:"(4) Where, under section 33, 33A or 33C, a coroner directs that a post-mortem examination of the body of a deceased person be made, the coroner may direct—(a) a person in charge of a hospital, or other health institution, in which the deceased person received treatment immediately before his or her death, or(5) A registered medical practitioner to whom medical records are given pursuant to a direction of a coroner under subsection (4) shall return those records to the hospital or other health institution or the medical practitioner, as the case may be, from whom they were received, as soon as practicable after the post-mortem examination of the body of the deceased person concerned has been made or, as may be appropriate, an inquest in relation to the death of that person has been held.
(b) a medical practitioner who has possession or control of medical records relating to the deceased,
to give to the registered medical practitioner making the examination, within such period as may be specified in the direction, such medical records relating to the deceased person as are, in the opinion of the coroner, necessary to enable a proper examination of the body to be made.
(6) A direction given by a coroner under subsection (4) shall be given in writing or, if given orally, it shall be confirmed in writing as soon as practicable.".
This amendment deals with the production of appropriate medical records of the deceased person for the purpose of a post-mortem examination. The new provisions provide that where a coroner has directed a post-mortem examination into a death, he or she may also direct the head of the hospital where the deceased person was treated immediately before the death, or a doctor who has medical records of the deceased, to provide the pathologist conducting the post-mortem examination with such records as the coroner considers necessary to enable a proper examination to be made.
The amendment is considered necessary to enable the coroner to carry out his or her statutory functions effectively and to ensure the fullest possible transparency in regard to the investigation of unnatural deaths or where the cause of death may be unclear. It is expected that such records would be provided on a voluntary basis on request by hospitals or other health institutions. However, difficulties have arisen in the past in certain cases where the coroner had considerable difficulties in obtaining appropriate records over a sustained period. It is particularly critical that relevant medical records of the deceased be provided in a prompt and timely manner. The window for conducting the most effective post-mortem examination is short, optimally often within 24 hours of the death. This provision is intended to make it clear that the coroner has the power to compel the production in case of difficulty.
Some of the finer points of this amendment are still being teased out with the Parliamentary Counsel. I intend to propose further amendments of the provision in question on Report Stage, particularly regarding appropriate enforcement provisions. We are considering in this regard what enforcement provisions would be most effective, having regard to the urgency that will obtain in the circumstances in question. I propose the acceptance of this amendment but with a commitment to consider adequate provisions in respect of enforcement. Possibilities might include, in addition to an offence, a power for the coroner to apply ex parteto the High Court should records not be forthcoming in a prompt and timely manner. I am happy to hear the views of members of the committee but I accept that while the amendment is important, we need to examine the matter of enforcement.
In fairness this was flagged to us as something the Government would address on Committee Stage, unlike some of the other issues, which I will deal with shortly. This issue definitely was flagged and we fully support the Minister in his efforts on this. I echo the point made by the Minister that our support on it is dependent on some sanctions being included on Report Stage. There are no sanctions at all on medical institutions or hospitals that refuse to hand over records. On the understanding that these sanctions will be included, I would be happy to accept the amendment. While this was flagged, a number of the other issues raised by the Minister were not flagged at all in the conversations we had in preparation for this Bill. I am pretty sure some of the issues were not even flagged on Second Stage. Some issues were flagged on Second Stage, dropped in the pre-discussions about Committee Stage and are now being re-entered. Perhaps the committee could deal with this after today's session. I just wanted to put it on the record. This issue, however, was flagged and we fully support it.
I also fully support this amendment. I would like to clarify the reference to registered medical practitioner. A pathologist is a registered medical practitioner and I presume that the pathologists would request this information. Is this understood? Heretofore, there has not been a mandatory release of full hospital records to pathologists and it has been a significant weakness. There is ample evidence of where this has not been done.
It is intended to bring forward an amendment on Report Stage to ensure the best and most effective approach to post mortem examinations. It would propose enhanced provisions, for example, on the conduct of post mortem examinations by registered medical practitioners and on the powers to remove and retain human tissue and other material during a post mortem examination. The provision may include a power for the Minister, in conjunction with the Minister for Health, to set out by regulation a code of practice for post mortem examinations. We do not have such a statutory code currently. I am also examine a provision for a new power allowing the coroner to request the Minister to order the exhumation of a body in the rare circumstances where the body has been buried but the coroner may be satisfied that further post mortem examination is required, and that such an exhumation is, in the circumstances, justified. There will be a provision for a defence post mortem. These are rare situations but may arise where a person is accused or is likely to be charged with criminal involvement in the death of a person very soon after the death. In such a situation the High Court has confirmed that the accused is entitled to request an independent post mortem examination of the body of the deceased in addition to the examination already carried out by the State pathologist's office. This independent defence post mortem differs necessarily in some important respects from a coroner's post mortem. For example, it is facilitated but not directed by the coroner. It is important that a statutory provision for the defence post mortem would provide more clarity for everybody concerned. I acknowledge that it is a complex area but it would enable provision, for example, for the appropriate balancing of the rights of the accused person and the family of the deceased. Defence post mortems can be distressing for the family of the deceased and any delay in this regard should be kept to an absolute minimum.
While the section amends section 37 of the principal Act, on Report Stage I intend to bring forward an amendment that refers back to section 17 on the matter of section 36 and the service of summons on the principal Act. It is merely an enabling provision to facilitate the serving of a summons on behalf of the coroner requiring the attendance of a person at an inquest as a juror or witness in the case of a death that is under investigation by the GSOC, for example.
I intend to bring forward an amendment to section 40 (3) of the principal Act, which suspends any obligation to have a jury in place if the inquest has been adjourned at the request of An Garda Síochána. I intend to reflect the intended amendments that are described in section 25, with particular reference to requests of adjournment of the coroner's inquest made by various statutory bodies other than An Garda Síochána, which might be charged with the investigation of deaths and including GSOC.
Similarly, under section 20 there will be an amendment to provide that a designated officer of GSOC - within the meaning of part 4 of An Garda Síochána Act 2005 - may assist the coroner in summoning a jury to an inquest where the particular circumstances of the case require such assistance.
Without wishing to be seen as intervening unnecessarily, I intend to bring forward on Report Stage an amendment to section 47 of the principal Act extending the power to request the exhumation of a body in some circumstances. Currently only An Garda Síochána has the right to so request.
I intend to bring forward an amendment that will propose to permit the involvement of a designated officer of GSOC in assisting the coroner's exercise of power under the section, in cases that fall under a GSOC investigation with particular reference to this section. It will provide for a new power for the coroner to enter premises by consent or under a warrant of the District Court, to take possession of any documents, articles, substance or item that might be relevant to the coroner's functions regarding a death. A warrant may be issued by the District Court if the judge is satisfied on the sworn information of the coroner that there are reasonable grounds to suspect that the premises contains such documents or things that may be required by the coroner for the purposes of the inquiry. This would involve the attendance of an appropriate officer from GSOC, should the circumstances warrant.
I indicate a proposed amendment providing for a new section to be inserted after section 61 of the principal Act covering the procedures for coroners in case stated circumstances. Subject to the advice of the Attorney General the intention would be to provide for a consultative case-stated-type process. It would allow for a coroner to apply to the High Court for directions on a point of law relating to the performance of his or her functions. Under the Act, it is proposed that the High Court would determine such an application by giving directions, making such orders as it may consider appropriate.
I want to reflect that, in common with other quasi-judicial bodies, coroners are being called upon to conduct inquests in a more adversarial and perhaps challenging environment than was heretofore the case. While coroners are not deciding the issue of adversarial litigation, they are nevertheless required to conduct an inquest in accordance with administrative law and they need to apply principles of procedural fairness. They need to comply with requirements of the European Convention of Human Rights Act. They increasingly deal with complex and sometimes challenging points of procedural law, which are raised by parties to the inquest from time to time. I merely cite an example of applications for discovery of documents to be provided to the coroner. All of these are positive for ensuring the system is adequately robust. I intend introducing a small number of amendments to the section.
In page 25, line 35, to delete “a hospital or other institution” and substitute “an institution”
This amendment is proposed on the advice of the Parliamentary Counsel to avoid possible confusion and even non-reporting of deaths in Schedule 2 as inserted by section 28. My concern is that referring to a hospital or other institution in point 23(a) of the schedule of reportable deaths that there could be an issue regarding interpretation. It might be interpreted as suggesting that other references to an institution in the Bill excluded a hospital unless that specific mention was made.
This Schedule, which section 28 inserts as a second Schedule to the principal Act contains a list of specific examples of the types of deaths that must be reported to a coroner under new sections 16(a) and 16(b) of the principal Act.
I take it that an institution for the care and treatment of persons with a physical or mental disability includes care homes managed by the HSE and by other entities, including across the section 29 cohort. This is now a catch-all for all situations, which it was not previously. It is for reporting to the coroner only.
I again thank the Minister and his officials for attending. I thank the members of the committee for their work and not just for their engagement. I especially thank Deputy Clare Daly who has put a considerable effort in over a protracted period helping to bring the Bill to this point.
I thank our visitors who have joined us this morning. History is a much used word, but, hopefully, this was an historic little moment that we have all been witness to.