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

I will try to be as brief as possible. I am conscious it has been a long day here, particularly for people in the Visitors Gallery, many of whom have travelled very long distances to be here. At the heart of this is the right to know. Too often in Irish institutions, as Deputy Wallace pointed out, when a mistake is made, the automatic instinct is to cover up, deny and make the problem worse. We have encountered that in many of our actions in respect of cases of Garda malpractice, where families may have lost a loved one through a murder or whatever. It is the same mentality that families here have met from the HSE and the health services. It is just not good enough. A modern society has to be accountable to its citizens. It has to behave openly and transparently in the interest of the public good.

As I acknowledged at the start, I appreciate the fact that the Government allowed this to be discussed today because it was off the agenda. It is important that the Government has agreed not to oppose it. That certainly never has happened to me in five years in the Dáil. This is the first thing that was not opposed, so that is a positive and I am not making light of it.

I am really strongly urging the Government not to lead people on. I am not unrealistic either. I know that it is the end of the lifetime of this Dáil and that there are only a couple of weeks of business left. It will be difficult to get this into a committee but I strongly urge the Government to do so.

Only the Government side can send business to a select committee, and only it can get this Bill to Committee Stage. I beg the Government to do that. From what she has said, I understand that the Minister is going to propose many amendments to the Bill. Many of them are to do with the rest of the Bill or the old Bill, and the work is well under way. That is grand. I accept it. However, I want to concentrate on the points made about this aspect, because we are very clear, and those who have done the research are very clear, that an automatic inquest is the way forward. While the Minister is most definitely not ruling that out, she did not say she was definitely providing for it either in the speech she put on the record today.

One of the points that concerns me slightly is the fact that the Minister referred to the arrangement provided for in the original Act, and which de factoexists now, whereby the coroner is required to investigate a maternal death. That is a different thing. The problem is that after an investigation, it is entirely at his or her discretion whether to hold an inquest. Really, it would only provide a legislative basis for the current rule of practice. At the heart of this is that when a reportable death is notified to the coroner, all he or she has to do is make enquiries as to whether a doctor can certify the cause of death. If the coroner has a doctor who signs off to the effect that it was a death from natural causes, there will not be a further investigation. That fulfils the requirement to investigate. In the case of Bimbo Onanuga, the coroner decided that there was no need for an inquest because the post mortem report carried out by the hospital was accepted as a full explanation of her death. When her partner fought valiantly for the inquest, the inquest told a horrendous story. I was there for part of it and, my God, was that hospital culpable. A verdict of medical misadventure was returned. That is the problem with requiring only an investigation. That is why we need it to be an inquest. An inquest is a public hearing where organisations whose actions are being questioned cannot hide, which is absolutely critical.

A point was made about whether there would be unnecessary inquests which would cause distress to families. I am, obviously, very sensitive about this and would like to ensure it would not occur, but we are talking about inquests in cases of maternal death. A maternal death within the timeframe we indicated earlier is a death from any cause related to or aggravated by pregnancy or its management but not from accidental or incidental causes. As such, maternal death in those circumstances would not lead to an inquest, and I think we are covered. The examples given of Baby McGarry and the family of Antoinette Pepper show that all families want this. Everybody wants closure and information. Given that the coroner has decided to grant an inquest into the death of Baby McGarry, and given that Antoinette Pepper's death occurred four years before that, the need for an inquest in her case is firmly back on the table. I reiterate that.

It is unusual that the Department of Justice and Equality is discussing this issue. It is a bit peculiar. What we are talking about here is really a health service matter, and the requirement for women and their families to have an assurance that we have gold-standard maternity services in place. However, it is clear from many instances to which other Deputies have referred over the past period that we have a dysfunctional maternity service. Sadly for many of those in the Visitors' Gallery, some of the assurances given by the Minister that matters would be addressed have not been followed up. That is a very real problem. The noted journalist Sara Burke, who has done extensive work in this area and investigated many of the cases, made the point that many of them related to poor and negligent care but that there were also a lot of other common factors. All the cases were initially denied and ignored until somebody blew the whistle or kept the pressure on. Families had to fight hard. Another key concern and trait was that catastrophic cases were not learned from. That is a huge problem. Given that an independent panel reviews the deaths of children in care, why do we not have a similar provision in respect of deaths in maternity units? It is an absolute must and would make things better for all. That is the key point and it is the motivation. Recommendations have been made by juries or coroners following inquests as to how to prevent similar deaths in the future and the HSE gave assurances that lessons would be learned and that clinical care and practice would change, but they did not. If they had, we would not be here and some of the families would not have suffered the losses they did. The point has been made that there was not even a nationally accepted definition of maternal sepsis even though there had been an assurance that there would be following the case of Tania McCabe. Following the inquest and investigation into the death of Savita Halappanavar, we found out that no definition had been put in place. Even basics are not in place. Statistical sleight of hand has been used to cover up the figures. The reality is that this is not the safest country in the world in which to give birth. There are huge problems of dysfunctionality in maternity services and there must be a complete and utter radical overhaul of that service.

The Minister for Health initiated a national maternity strategy to review this area, but there are concerns that this will not take on board some of the key contributions made by women and midwives. We have a rather structured and patriarchal system of maternity care in this country, which utterly needs to be tackled if we are going to get justice and the best levels of care. What has been done today is important. It is a stepping stone in raising awareness that would not have happened without the work of the people in the Visitors' Gallery. It puts on the map the Elephant Collective exhibition, which is going on a nationwide tour. That will help to educate people. In particular, it firmly puts the need for us to address the deficiencies in our maternity services centre stage. Things are too rooted in the old Ireland, the Ireland that allowed us to have women shackled in Magdalen laundries, which did not have a problem with women's pubic bones being sawn open to facilitate more deliveries of children and which did not have a problem expelling thousands of women out of this country every year to have routine abortions. It is just not good enough. Women know best for themselves and their bodies. Their families and loved ones know best how to get answers in their cases. We owe it to them and we really owe it to the children and partners of the women who are already dead to ensure that it does not happen again.

We are a bit tired and emotional after the week we have had, but it is an emotional subject too. It has been an utterly harrowing journey for the crusaders in the Visitors' Gallery and the Government owes them. Deputy Mick Wallace made the point that his policing Bill was passed on Second Stage but never went any further. I acknowledge that work has been done on this and accept the Government's bona fides in its assurances that the Bill will inform the new coroners Bill. However, I assure the Minister that people will not accept going down the road of an investigation. Public scrutiny is the only way forward for the institution currently called the HSE and for the management of many of our hospitals. I hope we have done a good day's work here today. I thank sincerely the people who are here to support us.

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