Mick Wallace (Wexford, Independent) | Oireachtas source

I welcome the Bill, particularly the new provisions proposed by Deputy Clare Daly to seek to make inquests mandatory in all cases in which a woman dies in the care of maternity services before, during or after giving birth. For far too long, the HSE has defaulted to defensiveness and denial when things have gone wrong. It has refused to engage with the causes of sometimes catastrophic mistakes in maternity services. It has forced families into long and exhausting fights for justice after the deaths of loved ones. By refusing to face up to and acknowledge the mistakes that have been made, the HSE is making it inevitable that more mistakes will be made. By defaulting to denial, it is prolonging the suffering of bereaved and devastated families.

As it stands, maternal deaths fall into the category known as "deaths reportable to coroner". Other reportable deaths include the deaths of children in State care or detention, deaths due to possible negligence, misconduct or malpractice, and cases of suicide. When a coroner receives notice of a reportable death, he or she will investigate it and decide whether any further action is necessary. An investigation is relatively cursory by comparison with an inquest, as it does not involve an intensive examination of the circumstances of a death. An inquest is the only mechanism by which all the circumstances of a death can be fully investigated and a verdict on the cause of death issued. Without this kind of comprehensive investigation in cases of maternal death, the same mistakes will continue to be made over again and women who should be alive may die through medical misadventure or negligence.

It is shocking that all eight inquests into maternal deaths since 2007 have issued verdicts of medical misadventure leading to death. It is inexcusable that in every case, the families had to fight tooth and nail for an inquest to be granted in the face of total intransigence from the HSE. It is devastating that the delays in granting an inquest into the death of Dhara Kivlehan may have contributed to the death of Sally Rowlette, who died in the same hospital as Dhara Kivlehan and from the same condition. If the hospital in question had learned lessons from Dhara's death, Sally may have been diagnosed and treated in time to save her. If it was standard for automatic inquests to happen in the case of every maternal death, all the women who have died through medical misadventure before, during or after childbirth in Irish hospitals might still be with us.

Transparency does matter. Owning up to mistakes matters. It literally saves lives sometimes. It is inexcusable that what we are seeking does not happen as a matter of course. We know from the eight inquests to which I have referred that information was withheld from families and that internal investigations and reports were withheld until the hospitals and the HSE were ordered to produce them by coroners in public hearings. We know that hospitals and the HSE said they would issue changed guidance and protocols to deal with similar events in the future, but they did not do so in many cases. If they did produce such guidance and protocols, they did not comply with them or did not carry them through fully. The HSE battened down the hatches in every case and hoped for the storm to pass. For the families, the storm can never pass until they get the truth.

In too many arenas of life in Ireland, there is a tendency to cover up and to deny. Ranks are closed when we raise questions in here about NAMA, the operation of An Garda Síochána and the breaches of international law at Shannon Airport. In most cases, the first port of call is to protect the organisation before protecting the public. In all of these cases of maternal death, the HSE has behaved in much the same way. Its instinct is to protect the organisation, regardless of the effect this has on patient care or bereaved families. In the past year, we have seen the HSE threaten legal action against HIQA to try to stop it from publishing a report that was commissioned following the deaths of five babies in a hospital's maternity unit. The report showed that the hospital in question had failed to learn from recommendations made in previous reports. It made it clear that there was a widespread lack of urgency in responding to risks in the hospital. It contained stories of bereaved mothers who were reprimanded for crying. It told of how one deceased baby was brought to its mother in a tin box carried on a wheelchair. The bereaved women were wrongly given the impression that their babies' deaths were isolated incidents. They were met with defensiveness, cover-ups and unfulfilled assurances. As I have said, the instinct is to cover up, deny and pretend everything is okay. It is not good enough. While the Bill can only address one aspect of the HSE's organisational instinct to cover up, we need better transparency right across the board within the HSE.

More generally, the Bill before the House will help to make Ireland more compliant with human rights values. The European Court of Human Rights has in several judgments noted the crucial role of coroners' inquests in fulfilling the State's obligation under the European Convention on Human Rights to investigate any death involving public authorities or institutions. The European Court of Human Rights has also interpreted Article 2 of the convention as providing for more extensive investigation of the circumstances of death. It has indicated that an extension of the scope of inquests is required to meet the obligations of the convention. The more information we have the better if we want to prevent avoidable deaths and improve services. These families should not have had their suffering so awfully compounded by having to fight to find out what happened to their loved ones. Things must change so that no family ever has to go through this exhausting, devastating and traumatic process again. Deputy Clare Daly's Bill will certainly help in that regard.

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