Fiona O'Loughlin (Kildare South, Fianna Fail) | Oireachtas source

Less than two hours ago, I spoke in the Chamber about the Scally report and how it sometimes felt that all we seemed to be doing was discovering another failure of the State in how it looked after women's health, their children, their rights to equal pay and pensions etc. Here we are again speaking about even more failures. I also mentioned how the trust that women placed in our health system had been let down.

Fianna Fáil supports this Bill, which strengthens and modernises the law governing coroners' inquests. I pay tribute to Deputy Clare Daly, who proposed a set of changes in 2015. Her proposal was prompted by inquests into maternal deaths between 2007 and 2013 that returned verdicts of medical misadventure.

My party, Fianna Fáil, supports the requirement that a maternal death automatically be the subject of an inquest. The Bill will allow a coroner to inquire into a stillbirth where there is cause for concern, for instance, raised by the bereaved parents.

Between 2011 and 2013, there were 27 recorded maternal deaths. That is almost 14 per year. It is a high number. Of these, only three were the subject of an inquest. I have reason for being close to this matter, as one of those three involved a friend who was married to another friend of mine. She was Nora Hyland. I remember her death in February 2012 well. Many times afterwards, I sat with her bereaved husband and her motherless son, a very small baby who had been born approximately two hours before Nora passed away. I remember trying to understand the grief, the trauma and the many unanswered questions as to why this lovely woman had died. The other two cases that were eventually granted inquests were those of Savita Halappanavar and Sally Rowlette.

I will mention one other woman, Dhara Kivlehan, who suffered complications in Sligo and was referred to Belfast's Royal Victoria Hospital, where she died. I mention her specifically because I spoke to Stephen Hyland an hour ago about the difficulties he went through at the time. When I was first elected to the Dáil two and a half years ago, he texted me to say "Well done" and that he might need to contact me about an automatic right to an inquest after a maternal death. This debate was effectively arranged at the last minute, so I rang him to say that I would now have the opportunity to repay our friendship and discuss the situation. He told me that lives could have been saved had there been an automatic inquest. Sadly, Dhara died after being referred to Sligo and then brought to Ulster. Her family had to fight and fight to get an inquest. During that fight, another woman died, Sally Rowlette, who had also been referred to Sligo. After both inquests were concluded, it turned out that both women had died of the exact same syndrome. Had an inquest been held into Dhara's death, the hospital would have known what to watch out for and Sally's life could more than likely have been saved. The doctors would have recognised the symptoms.

Here we are five years later. The proposed changes should have happened before now, but at least they are being made now. Other changes also need to be made, but we need to move on this and discuss the good elements proposed in the Bill.

The Bill addresses a key problem, one that the Minister mentioned, that continues to cause great public unease. In a number of high-profile cases, and some not-so-high-profile cases, of maternal and perinatal deaths, deaths occurring in hospitals that should have been reported to coroners because they raised issues of medical error and were unnatural deaths under the Coroners Act 1962 were not actually reported. This has certainly led to inconsistencies in the way in which maternal deaths have been recorded in official statistics. A strengthening and modernising of the current law will allow lessons to be learned to prevent the recurrence of errors and such deaths.

The Bill will allow a coroner to inquire into a stillbirth where there is cause for concern raised in particular by the bereaved parents. We must remember that these are incredibly sensitive and private matters for traumatised mothers, husbands, partners and families and need to be dealt with in the most sensitive, but professional, manner.

They should not have to fight to obtain basic information at a time when they are at their most vulnerable. Families have wasted years fighting for inquests into the deaths of their loved ones. The fact that it has, in the past, proved difficult to persuade a coroner to hold inquests into maternal deaths has resulted in a lack of transparency about the incidence and causes of maternal deaths. This prevents lessons from being learned which could prevent the recurrence of errors. The inconsistency with which maternal deaths have been recorded has led to significant under-reporting of these incidences. I was quite shocked when I learned of 27 maternal deaths within two years.

Decisions of the European Court of Human Rights have stressed the obligation of states to investigate unexplained deaths or those that occur in circumstances that involved official persons or authorities. The court has explicitly pointed out that the State's obligation can extend to deaths than occur in hospitals, to be able to establish the cause of death and any liability on the part of health professionals. It is clear that this legislation is required to ensure Ireland is compliant with the European Court of Human Rights. On a broader note, bereaved families and coroners have experienced considerable difficulty in obtaining basic information which should have been provided to them. They should not have to fight to get this information. The increased powers afforded to coroners by this Bill is welcomed. My party will bring forward amendments on Committee Stage to help strengthen these provisions. A complete reorganisation of coroner services under a national coroner services body, as envisaged by two previous Bills, including a Government Bill in 2007 and Deputy Clare Daly's Private Members' Bill in 2015, is not provided for in this Bill. This Bill did not go through pre-legislative scrutiny and so it is not clear what the Government's rationale is for limiting the extent of the overhaul. We want to know why. Once the Government has outlined the reason for this, we will consider the merits of that decision or decide not to support that and to bring in our own amendments on it.

It is important to look at the most significant and important provisions. The first is to provide for new categories of deaths that must be reported to a coroner, including maternal deaths and late maternal deaths. The definition of late maternal death is the death of a woman more than 42 days but less than 265 days after the end of her pregnancy. Other new categories include stillbirths, deaths of infants during birth or in the first year of their lives, deaths by suicide, deaths by drug reactions or overdoses and deaths that may be due to healthcare-acquired infections.

The Bill allows inquests to examine the circumstances surrounding a death and not just the cause of death as is currently the case. This will not entail the coroner considering questions of civil or criminal liability but the coroner will be concerned with establishing the circumstances of the death as distinct from making findings in respect of it.

The Bill enhances the powers of the coroner to procure post mortem examinations; to obtain documentary and other evidence; to summon witnesses; to apply for search warrants; to take evidence from a witness who is likely to be outside the State at the time of an inquest at any time before the inquest; and to obtain expert advice or assistance.

The Bill introduces new offences for failing to abide by requests of the coroner. Failure to answer a question at an inquest is an offence and there will be a new offence of giving false or misleading evidence to an inquest.

There will be improvements for families of deceased persons, including for families of deceased persons to be kept informed about the work being undertaken by a coroner. Communication is vital for families that are going through grief. I mentioned the Scally report earlier. A doctor's response to a woman when she asked when she would know was that she would see it on the news headlines or television. We do not want that here. The Bill provides for civil legal aid to be provided for families of deceased persons. I acknowledge that the Minister indicated that he will, subject to advice from the Attorney General, seek to put forward amendments on Committee Stage to authorise coroners to inquire into stillbirths where there is cause of concern; to allow a coroner to seek directions from the High Court on a point of law in relation to the performance of their function; to provide for coroners to direct a hospital to make available the medical records of deceased persons; and to provide for the Minister to make regulations on the proper storage and disposal of any material removed during post mortem examination.

When the Minister of State spoke earlier, she mentioned the public unease that all of these very sad cases brought about. She was right in that because there was huge public unease. We have to remember the private grief, trauma and sorrow of lost daughters, sisters, wives, partners, mothers and friends. I would love to stand here and say that we will never have a maternal death again. Of course we will but we have to ensure that when there is a maternal death, all the supports needed for the mother's family will be met and there will be a post mortem examination into the death and all the circumstances surrounding it. I commend this Bill and I again commend Deputy Clare Daly.

See this speech in context