Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance) | Oireachtas source

I commend Deputy Clare Daly on bringing forward this amendment Bill. I also pay tribute to the families who have lost loved ones, who have come here today and have campaigned for this change to make the Coroners Act 1962 what it should be, in order to deal with the situations and circumstances of today. An overhaul of the Bill is long overdue. We must ensure that people who lose loved ones in maternity services have full justice and get full disclosure and information about the tragic circumstances without having to fight for it, often against the impulse of institutions, hospitals and authorities to cover things up when mistakes have been made. Their refusal to acknowledge mistakes, for whatever reason, fear of the legal consequences or financial cost to the State, whatever it is that leads institutions to cover things up or to deny mistakes and misadventure, causes additional pain, suffering and frustration for people who have lost loved ones. The Government cannot act a moment too soon to do everything in its power to ensure that sort of injustice and cruelty is not visited for one moment longer on people who are already suffering tragic circumstances.

I know personally of the distress caused following a death when I lost a daughter within a few weeks of her being born. There was no instance of medical misadventure but it was a shock to lose my own daughter. In the weeks leading up to her inevitable death all we wanted was information, the truth about what was happening, because it is hard to understand that one is going to lose someone that one loves and that one wants to live.

We must do everything we can to ensure that people who suffer these tragedies and who are victims of medical misadventure get full disclosure, accountability and the truth about everything that has happened to their loved ones. That is particularly important given the State’s terrible history when it comes to the treatment of women and the suffering that has caused because of the State's attitude towards women. It is doubly important that on the specific issue of maternal deaths during or after pregnancy there is a requirement for the fullest possible investigation. It should not be left to the whim of the coroner to ensure there is a full inquest.

I commend Deputy Clare Daly and hope that the Government will not just oppose this Bill but will move it through the House and bring about this necessary and overdue change as quickly as possible.

I also want to take the opportunity to raise a particular case which concerns an infant death in maternity services. There was a similar battle by the parents of that infant for the truth about the death of their daughter, Jennifer Anna McGarry. I talked to her parents again today because I was aware that this Bill was before the House and it was an opportunity to raise the issue. I first met Stephen and Catherina McGarry, who are from Sallynoggin in my constituency, in late 2013 when they told me their terrible story involving the tragedy and the injustice they then faced. They faced this injustice more recently at the hands of the HSE, but this dates back to the death of their daughter Jennifer Anna in 1991 in the Coombe Hospital, when it would have been under the Department of Health. They are still seeking the full justice, disclosure and accountability that they have not received in respect of the death of their daughter.

I will briefly outline what happened. Jennifer Anna was born on 28 November 1991 and died on 14 February 1992 in the Coombe Hospital. The registrar's report of the time described the birth as a routine delivery. In fact, a subsequent investigation reported that midwives said that it was far from routine and was a very traumatic delivery involving the use of forceps, which resulted in catastrophic spinal injuries to Jennifer Anna and her subsequent death. An internal post mortem was held following her death, but the requirement under the Coroners Act that the case be referred to the coroner was not discharged by the hospital. It never passed on the details of the case to the coroner to look at. Subsequent to that and without the permission of the parents, the baby's organs were taken and the parents never got them back. As they described it, they buried a shell. This happened without their permission. Catherina became ill a year later and had a stroke. She had a number of miscarriages when they tried to have children afterwards. They certainly believe there may be a connection between the traumatic delivery and death of their daughter and her subsequent health problems and inability to have a child. As they see it, this ruined their lives and their hopes for their lives.

They have been fighting ever since for a proper investigation into this case. Twenty-three years later, after campaigning against every kind of obfuscation, frustration, denial and, as they would see it, cover up, a report was produced in November 2015. I suspect it was partly because I tabled parliamentary questions in November 2013 and because of the continuous, relentless and courageous campaigning of Stephen and Catherina. This investigation acknowledged everything they had contended all along. It said that there should have been a Caesarean section at an earlier time in Patient X's labour due to the failure to progress the labour and that this would have resulted in Baby X - Jennifer Anna - not being delivered by forceps, thereby most likely preventing the injury to her spinal cord that occurred and that eventually resulted in her death. It also acknowledged the failure to hand the case over to the coroner and that consent should have been required for the removal of Jennifer Anna's organs.

The other part of this story is that the doctor at the centre of this who carried out the forceps delivery subsequently moved to England and, in the years afterwards, was the subject of 40 separate complaints by mothers whose babies he had delivered and was ultimately suspended from practice. Judging from the evidence in England and the reports, it appeared that he was somebody who had systematically engaged in medical misadventure or negligence, whatever you want to call it.

Stephen and Catherina got an apology, but they have not had accountability or a real explanation. Most recently, this case has been raised by Deputy Martin in the past couple of weeks. Catherina and Stephen have asked to meet the Minister to explain what they want. To put it simply, they want a fully independent investigation that establishes why the Coombe Hospital broke the law in not referring this case to the coroner, and why it took 23 years to force some kind of investigation - one that has still not really acknowledged why the incident happened and who was responsible. I appeal to the Minister of State not just to support this Bill but to consider this case and the need for more robust legislation in this area when it comes to reportable deaths of children in maternity services and the requirement for full inquests, and, in this specific case, the need to give Stephen and Catherina the meeting with the Minister that they want and an independent investigation into the death of Jennifer Anna, which has dominated their lives ever since and caused them such hardship and suffering.

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