Clare Daly (Dublin Fingal, Independent) | Oireachtas source

It is absolutely incredible in some ways that we are dealing with a situation where the coronial service is operating under legislation dating back to the 1960s and in spite of the considerable changes that have taken place in society since then, we have not been able to get our act together to modernise the legislation. I am aware that secondary legislation behind the scenes did change the situation somewhat. I had the privilege of attending a coroners' conference two years ago. I know the good work they do, how under-resourced they are and how they have striven might and main to demand of this House that legislation be changed to allow them to do a job they could do in the public good. In that sense it is tremendous in some ways, while shocking in others that we are operating against that backdrop, but at least we are here now with the first legislation that I hope will be enacted by the House to update the situation somewhat.

I will not go very deeply into the details of the legislation. The Minister has done that and other speakers have also done so. However, the provisions in the Bill do arm coroners more and give them more power, which is to be welcomed. I reiterate the point made by the Minister that we have been in discussions about the amendments that, unfortunately, did not make it into the original draft of the Bill, but there has been a commitment by the Minister and the Department to ensure that when we reach Committee Stage, some important amendments will be included. I assure people in the Gallery that we have gone over those amendments that will be included in the later Stages with a fine-tooth comb and, by and large, we are very happy with them. I thank Brendan McNamara and Madeleine Reid in particular. This House is very good at criticising the Department of Justice and Equality in particular, which comes in for a justifiable kicking a lot of the time, but it is also very important to recognise the good work done. Any delays to the Bill were not as a result of the staff at the coalface.

Neither were the delays due to the Ministers either, given that the Minister, Deputy Flanagan, said it is a priority for him and it was most definitely a priority for the previous Minister, Deputy Fitzgerald, who elevated the Bill as a key project item for the Department. One could ask what that says about society that in spite of not one but two Ministers prioritising this important area, it has been an almighty uphill battle to get where we are today and to get a recognition, which was not there in 2015 when we introduced the legislation. That was despite the fact that the Government of the day largely welcomed the Bill but it had reservations about many clauses in terms of mandatory inquests in cases of maternal death which are now being incorporated in the Bill.

While that is great on one level, it is a tragedy that it has taken so long for us to get here. We must be honest. The only reason it is here is because of the heroic struggle led by the people in the Gallery in support of the victims of the lack of mandatory inquests, namely, the people who have been at the coalface, whose human tragedies have been turned into a movement to try to change the law for the betterment of others. It is quite incredible to meet the families of the women who died in maternity hospitals. I will mention them all later. I refer to people like Sean Rowlette who lost his partner in childbirth and came home to three children, including a new baby, who had to run a farm and who probably never did a household chore in his life before. He had to deal with all that, raise his children on his own and he still had the courage and the decent humanity and empathy to turn his grief into something constructive in order that no other family would have to do that. That is what people like the partners of many of the women who died, the midwives and the foot soldiers in the Elephant Collective have done to get us here. I have no doubt but that this would not have happened without their efforts.

That is a recognition of them but it is also a shocking indictment of our system.

We have a problem with women in this country: the women are not the problem but, rather, the healthcare that is given to them before, during and after they give birth. Our health system has infected women with hepatitis C, taken hacksaws to their pelvises, unnecessarily removed their wombs and refused them abortions in the most unspeakable circumstances. The pain of women affected by the recent vaginal mesh scandal was dismissed as being in their minds. Women went to doctors and reported their appalling pain and problems but not a single doctor reported that to the Health Products Regulatory Authority, HPRA, which continues to prescribe vaginal mesh for the treatment of women. Women have been refused treatment and treated as incubators even while their families begged the State to let them go. The State has threatened to imprison women who did not want to undergo an unwanted caesarean section. It has insulted women and ignored them when they tried to speak up. It has left them traumatised and reeling. After all that is done, the State inevitably gears up for another go at women, dragging them and their families through the courts. That is the backdrop to this issue.

This is particularly shocking in the case of maternal deaths because it involves healthy women who entered our hospitals with the justified expectation that their experiences in hospital would not leave them psychologically or physically scarred. They justifiably considered it almost unimaginable that they would die in hospital. They held the justified expectation that, should something go wrong, they and their families would be dealt with honestly, openly, respectfully and transparently. How often is that expectation fulfilled in our health system? It gives me no comfort to say that it is rarely lived up to. It took the victims of the hepatitis C scandal years to have their issues addressed. The victims of symphysiotomy are still fighting for justice in the latter years of their lives.

Women have walked into our maternity hospitals and walked out days later with post-traumatic stress disorder. According to Nurture, a charity which supports women, thousands of women experience post-traumatic stress every year following treatment in our health service. We are told that the Coombe and Holles Street hospitals are not war zones, although some of the midwives in the Public Gallery may disagree with that. However, if they are not war zones, what causes the post-traumatic stress suffered by pregnant women in our hospitals? Among the 15 problems identified in that regard are impersonal treatment, problems with hospital staff, not being listened to and a lack of information or explanation. Dismissing, ignoring or denying information to patients has real lifelong consequences for them. It is not minor but, rather, a frightening mark of the paternalism that still infests our maternity services that we are so far behind the curve in terms of being honest with women about what is happening to them and why.

Families whose healthy babies suffered catastrophic birth injuries leading to lifelong disabilities have had to fight for a decade or more to get resources for their children. It has taken ten or 15 years for the HSE finally to cough up. A sample of 30 baby deaths due to negligence in Irish hospitals between 2008 and 2016 was compiled. In each of the cases in which an apology or settlement was recorded, it was received three to nine years after the baby died and many of the cases involved no admission of liability. Why are innocent people subjected to this abject cruelty? Why is it happening? We can re-examine such issues but part of this discussion should be about looking forward. What causes those delays and hesitancies? Is it to keep insurance companies happy or premiums down? Is it institutional inertia? Is that why our hospitals subject people to what in some ways constitutes arbitrary torture? All of the international evidence indicates that if doctors and healthcare staff are open and honest with patients when something goes wrong, the patients are far less likely to sue. It suggests that many of those who sue do so to get answers rather than redress. I make that point because it is very relevant to inquests and getting information.

Exactly one year ago, Deputy Wallace and I sat down with senior officials of the HSE to discuss mandatory open disclosure. The officials were totally against it. The only reason we were given a meeting with them was that some of our amendments to the Civil Liability (Amendment) Act 2017 were unexpectedly accepted and called for mandatory open disclosure. Suddenly, the officials wished to meet us to tell us it was a bad idea, without offering any supporting information for that view, and to persuade us to reverse the amendments. Now, of course, mandatory open disclosure is the order of the day because of the CervicalCheck scandal. Everybody wants it, including those who voted it down last year when we had the chance to provide for it in legislation. It is a sad indictment of this House that victims could have obtained answers in the past 18 months if we had enshrined it in legislation at that stage.

This Bill is very much aligned with the push for open disclosure because we need a health system that works for women and their families and does not compound their suffering by denying, defending or covering up in the face of tragedy. That is why we need mandatory inquests and mandatory open disclosure. We need pre-action protocols to get the lawyers out of our hospitals. That is not news. A recent editorial in the Irish Medical Journalstated that in many hospitals the medico-risk management department is larger and better staffed than the library. There is something deeply wrong with a system that spends more on damages and legal fees than on funding our maternity services. This Bill should be part of a suite of measures to address that. There is often discussion of a litigious culture in this State. Is it any wonder that people are forced to take recourse to the law when they do not get answers? This Bill is a start in addressing that issue. It has been a long road to get to this point but the Bill will move things onward.

I became involved in the issue of maternal deaths more than seven years ago, in May 2011, when I was contacted by AIMS Ireland, which sought help in raising parliamentary questions as to why there had not been a full inquiry into the tragic death of Bimbo Onanuga in the Rotunda Hospital in March 2010. We have stayed in touch with the warriors who are present in the Public Gallery since we first tabled questions on that case. We did what we could to support them in the effort to get an inquest for Bimbo. On 12 December 2012 the coroner finally agreed to hold an inquest. In November 2013, after four long days of hearings spread over eight months, he recorded a verdict of medical misadventure in Bimbo's death. I attended the inquest, which was shocking and devastating in equal measure. What is more shocking is the fact that before her inquest took place six women lost their lives in our maternity services in the autumn of 2012. There were inquests into only two of those deaths. In the autumn of 2014 three further inquests were held, each of which returned a verdict of medical misadventure.

The onus was on all of us to do everything we could to prevent more tragedies and step up the fight in honour of the women who died and their families, so we introduced the Bill in 2015. It has been a long road since then. Between 2007 and 2014 the families of Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Khivlehan, Nora Hyland, Savita Halappanavar, Sally Rowlette, not satisfied with the partial explanations offered to them by the HSE, had to fight tooth and nail for inquests. They needed to know why healthy women who attended early and appropriately for ante-natal care and were fully in the care of our system died. They needed to know that for all of the reasons earlier pointed out by Deputy Fiona McLoughlin and in order to learn lessons and prevent it happening to other women. That is the step we must reach. Two or three maternal deaths occur in all categories in Ireland each year. We need to know in full what happened and what lies behind the deaths. We cannot rely on confidential or internal inquiries and so on because hospitals and the HSE hide the truth behind them. It is timely and relevant that we are having this discussion on the back of the earlier statements on the Scally report. We need public inquests for the families involved in these awful tragedies in order to enforce genuine accountability for the terrible failures in the known cases but also in all the cases where an inquest should have been held but was not.

The pain does not go away for people. Only last week, I happened to meet a Polish man, who has lived in Ireland for many years, whose wife died in childbirth in 2011. That man's family, story and name has not appeared in any statistic or book, and I will not reveal them here tonight, but his pain is as fresh today as it was seven years ago. He still has not got answers. Because of what happened during the traumatised birth of the child, the child was also damaged at birth. He has been raising that child alone for the past seven years. He has not got any answers since the time he was sedated in the chamber as he begged the staff to save his wife's life, only for it to be too late.

There are cases where people never got the answers. I want to put on the record the names of the partners of the women who championed this issue but I do so in the spirit that there are names of women, their partners, their families and their children who have not made it onto the Dáil record who never got an answer. I mention the names of those we do know out of respect also for those we do not know. They are Sean Rowlette, Michael Kivlehan, Abiola Adesina, Aidan McCabe, Stephen Hyland, Francis Crean, Padraic Flanagan, Praveen Halappanavar and Alan Thawley. Let us be clear. Since we introduced this legislation the first time, Malak Thawley has sadly died an unnecessary death that had to be dragged out through litigation by her partner, Alan, yet it happened again. The reason people sacrificed their time and energies and laid bear their most personal tragedies was to ensure it would not happen again. That is the reason we are here.

People want to thank me but there is no need. I am an office, a brand. The brains behind my office are the ones who did the work, namely, Aideen O'Sullivan, who is in the Gallery, and also Liz Cassin and Ronan McCourt in my office, who regularly fight this battle and liaise with all the people we have had the honour to campaign with. There is no need to thank us. That is our job.

However, the people in the Elephant Collective have been tireless campaigners in the run-up to this Bill. They travelled the country with their "Picking Up the Threads: Remaking the Fabric of Care" exhibition. They have written letters, postcards and press statements and they have talked to local councils. We have the privilege of knowing that many local councils the length and breadth of this country, with members of all parties and none, have supported their call for mandatory inquests in cases of maternal deaths. Those in the Elephant Collective are the most amazing group who have ever come together. Their work on this campaign, and their doggedness, tirelessness and kindness have been incredible. It is a lesson in terms of the type of approach we should have in our health service: that of caring, collective empathy and human understanding.

Everybody makes mistakes. The best health service in the world will make mistakes. Women will go into hospital healthy and happy and they will die in childbirth this year. Sadly, that is a fact of life, but we can minimise those cases if we learn the lessons, and mandatory inquests are part of that. To that end, this legislation will be a testament to Jo Murphy-Lawless, who is retiring tomorrow - that is why she is making me cry - having given a lifelong service to women, and pregnant women in particular, and to student midwives. Trinity College Dublin has been so lucky to have the brains, the passion and the commitment of this tiny woman who is an absolute giant. The fact she is retiring from this active phase of her life with Trinity College and going on to bigger and better things is an incredibly fitting testament to her that we are here tonight. We owe it to her to ensure that we try to get all Stages of the legislation passed and enacted before Christmas.

See this speech in context