Clare Daly (Dublin North, United Left) | Oireachtas source

I move: "That the Bill be now read a Second Time."

I acknowledge it is the 11th hour as we have almost reached the Christmas break but I am glad we are discussing this legislation. Earlier this week, when I thought I might not be around for a few weeks, this was the only item of business that I would have been gutted to miss. It is not that other issues are unimportant but this Bill is particularly special and getting this to the next Stage is an opportunity for us to do something important for women. I thank Deputy Joan Collins who had undertaken to stand in if I was absent today and I also thank the Government, having amended the schedule originally and taken the Bill off, for agreeing to putting it back on. I am also especially glad to hear the Minister has indicated that she will not oppose the Bill and will allow it to pass Second Stage. I am keen that we try to follow that up and get the legislation into committee because this is the culmination of a huge volume of work that has not been done by me. I am only standing on the shoulders of others. I am humbled to introduce the legislation and I am conscious that all I am is a voice and a vehicle for the efforts of others who have led the fight on this issue, many of whom are in the Visitors Gallery. They are responsible for putting the issue centre stage.

I refer to the incredible, almost unspeakable, bravery of the husbands and partners affected who had to deal with their own grief and personal loss alone and then, on top of that, had to battle to have inquests held to find out what happened to their wives and partners. I also refer to the resilience and tireless crusading by people such as Dr. Jo Murphy-Lawless and all the other educators, midwives, student midwives and birth activists who have striven to raise public awareness to make maternity services safer for women. Their efforts are reflected in this Bill. It is mad to think that almost ten years ago on 20 December 2005, the then Government approved the drafting of legislation that later became the Coroners Bill 2007.

That Bill incorporated many of the recommendations of the coroners review group in 2000 and the coroners rules committee from 2003 in order to update and overhaul the functions of the coroner, which is currently governed by the Coroners Act 1962. We all know a hell of a lot has changed since 1962 and it is absolutely unacceptable that this issue has not been addressed before now. It has been on the Government's books but there has been no progress to date, which is not good enough.

Women's lives matter and we have a chance with this Bill to acknowledge that and address inadequacies in the current system. My Bill largely takes the 2007 Bill and makes two crucial additions. The first would amend section 53 of the Act, dealing with circumstances in which a coroner must hold an inquest to include all cases of maternal deaths, and the second amends section 75(1), which covers mandatory post mortems and special examinations, again in the case of maternal deaths. This would be absolutely critical. The original Bill refers to "investigation" but, to be honest, it would be up to the coroner whether the process would go further, which is just not good enough.

This Bill is simply about triggering an automatic inquest into a maternal death, which is a death during or following pregnancy up to six weeks post partum for any hospital or maternal care unit or other location where women are under the care of an obstetrician or midwife. Why do we need this? It is an urgent matter that we enact this into law in the lifetime of this Government. The reason is best expressed in the letter written by the children of Ms Sally Rowlette to the Minister for Health, Deputy Varadkar, last year. They stated:

We miss our mum so much every day. Can you please make sure this will never happen to any other mum again and make our hospitals safe? We have to learn from these tragedies to help minimise and stop them occurring for others.

Sally's husband, Seán, and Michael Kivlehan, who lost his wife, Dhara, days after the birth of their son met the Minister, Deputy Varadkar, earlier this year but have yet to see realised any of the promised improvements they were told would be put in place. That is why this legislation is urgent.

We hear much about Ireland being one of the safest countries in the world in which to give birth but in the absence of accurate statistics, it is a groundless assertion. In 2007, two courageous obstetrics consultants pointed this out in a public letter to the Irish Medical Journal, indicating that our national maternity mortality statistics were under-reported, suffered from poor validation methods and were not reliable. That is a fact. In 2007, Tania McCabe lost her life, and she was followed by Evelyn Flanagan later that year. These were the first of the eight cases where public inquests eventually ruled that medical misadventure was the cause of death for healthy, pregnant young women. The others were Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette. We are here in their memory, battling for their families, and also as people who never knew these women. We are saying that this cannot happen to other women in 2015 and it is just not good enough.

In 2009, moves were made to collect accurate figures for maternal deaths with the establishment of the Maternal Death Enquiry. In its first report in 2012, it stated that data collection was only slowly improving and that it remained incomplete. It identified problems such as an inconsistent approach to data classification, a lack of a national approach and the need for a question on pregnancy status at time of death to be included in all coroner certificates. It also pointed out that there was incomplete engagement on behalf of many of the hospitals, particularly general hospitals with maternity units. One of the fears seemed to be that these institutions were fearful of litigation. Instead of being open, transparent and accountable to patients, they instead ran for cover and went on the defensive when families sought to ask questions and have concerns answered.

That was well articulated in some of the interviews given by Seán Rowlette and Michael Kivlehan, who spoke about counteracting sorts of cover-up when they needed full disclosure. Although their wives cannot be brought back, they do not want others to suffer in the same way. They spoke about the arrogance and incompetence that they saw in our maternity services and how they had to battle for years to get inquests. We know others never got an inquest. When I asked the relevant Minister about this earlier in the year, she said she was not really keen on the idea as it could impose unnecessary further distress on the families of the deceased. The people in the Gallery are testament to the experience that people need answers and closure; a public inquest is the only way in which to deliver that. Deaths by medical misadventure are an unintended outcome of an intended medical action. An inquest does not apportion blame or anything like it but it allows the opinion to be entered on the death certificate.

Last year, after the deaths of babies in Portlaoise, the Minister, Deputy Varadkar, correctly stated that those families had been lied to. Lying has been a persistent reality for the families in the Gallery and those which have faced the tragedy of maternal deaths. We know that has been true for a considerable period, from Helen Moynihan in 1981 to Antoinette Pepper in 1988, whose family fought resiliently to try to get an inquest into her death. They still have not achieved that goal but I put on record again a call for an inquest into her death. What all these families share is the experience when seeking answers of meeting well defended and very partial explanations. They were often told there would be internal investigations and they should not worry. They had to fight for inquests and they needed to know why healthy women who had come early and appropriately for antenatal care - all fully in the care system - had died. They would not know the answer without an inquest.

We know from inquests into the deaths of these eight women that vital information was withheld and they were often not privy to the internal investigations and reports until the HSE was ordered to produce them by coroners in public hearings. We know that although hospitals and the HSE indicated there would be changed guidance and protocols to deal with similar events in future, they were not implemented and carried through fully. That is a shocking statement and I am in no way saying it lightly. If the HSE recommendations issued on foot of the inquest following Tania McCabe's death had been made enforceable national policy, Savita Halappanavar may not have died. It is also the case in the death of Dhara Kivlehan. If her inquest had not been obstructed and delayed for four years from when she died in 2010 to the inquest in 2014, Sally Rowlette, who died in 2013 in the same hospital from the same failure, may not have died either. This is an incredible statement about a health service in 2015 but it is true. That is why it is critical that not only should allow the Bill pass today but we should get it through Committee Stage and begin to make it operational.

The Irish Maternal Death Enquiry team released its latest briefing document this week and between 2011 and 2013, there were a total of 27 maternal deaths occurring during or within 42 days of pregnancy. People were interested in the death of 88 gardaí in the history of the State, which is significant, but there have been 27 maternal deaths in two or three years, which is much more dramatic. Of those deaths, seven were classified from direct causes and of those, only three had inquests. Knowing what we do from inquests about lack of care and appropriate and timely diagnosis, it is clear we needed those other four inquests into the deaths. This could only be done properly with an automatic public inquest. We have two to three maternal deaths of all categories in Ireland every year, which is a phenomenal figure. We need to know in full why a death happened and what lies behind it.

We cannot rely on confidential inquiries because hospitals and the HSE hide behind them. That is a fact. The only way to get transparency is through accountability, with public inquests so that families get answers but also to enforce genuine accountability on the part of the HSE. Unfortunately, as matters stand, we do not have that.

All pregnant women need to know that the maternity services and the HSE will be accountable for both genuine continuity of care and an end to the fragmentation of services. They need to be able to rest assured that there will be excellent communication between doctors, midwives, themselves and their families and that there will be an to complacency and to not listening to these women and their families. We should have an international gold standard in terms of maternity care rather than rhetoric from the HSE. The idea of an automatic coroner's inquest will give families the truth, it will give transparency and it will give the wider community a way to hold the HSE to account.

Many of these conclusions are based on the outstanding work of Dr. Jo Murphy-Lawless, who is in the Gallery. These are her words. She has been a pioneering crusader on these issues and the awareness that exists in Ireland with regard to these matters would not have happened without her. I want to refer to the wonderful exhibition by the Elephant Collective that many of the women are involved in, which is very aptly titled "Women's Deaths Remembered: Picking Up the Threads, Remaking the Fabric of Care". It is based on a knitting exhibition to remember all the women who died tragically in the care of our maternity services. It involves beautiful paintings, a documentary, and a wonderful remembrance of those vibrant young women, but also a reminder of the importance of making changes for the future. They very poignantly use the name "the Elephant Collective" on the basis of the behaviour of elephants who, it appears to me, are much more civilised than human beings or than many institutions in Irish society. When an elephant gives birth, the rest of the herd surrounds her to protect her and her calf. What we are being asked to do today, in pushing this Bill, is to be that herd, in essence.

Our society has let women down. We have to be honest about that. From the Magdalen laundries to symphysiotomy to our current lack of bodily integrity in respect of abortion and to the eight women who so unnecessarily lost their lives through medical misadventure. It is not just those eight women, it is also about those others who did not even get an inquest. We must learn from those tragedies. It is that simple. We must raise awareness about this issue. We have to ensure there is an automatic inquest and vastly improved disclosure methods in terms of hospitals and the HSE reporting on tragic and adverse incidents in our maternity services. It is only by doing this that we can open them to more public scrutiny and give women in Ireland and their loved ones and families the type of care they rightly deserve.

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