Clare Daly (Dublin Fingal, Independent) | Oireachtas source

These two amendments are at the heart of the issue. This is where we diverged from the Government on Committee Stage. Of course, I am absolutely delighted there has been a change of heart on that side and that the Government now agrees with us that inquests must be 100% mandatory with no discretionary loopholes through which cases might disastrously slip. I am also delighted that the coroners are very much on board with the process and doing away with the discretionary element. I sincerely thank them for their patience, help and wisdom throughout the long process of getting the Bill to where it is today. That is important.

I remind everyone why we are here. I discussed it briefly when speaking on the previous group of amendments. We have been joined by some of the stalwart campaigners in the Gallery. The campaign started with the tragic death of Bimbo Onanuga and the titanic struggle her family had to go through to get an inquest into her death. Her family was not the only one. Between 2008 and 2014, inquests were held for eight women who died in maternity services, all of which ended in verdicts of death by medical misadventure. In other words, all of the deaths were avoidable. Families had to fight tooth and nail for every one of those inquests, adding trauma to the tragedy they had already experienced. We are here, and I am very glad we are, to make sure it never happens again.

We are also here to honour the memories of all of the women who died in pregnancy or childbirth in this country over a long period. I am getting very emotional; I am obviously too tired. We are here to reiterate our commitment to the families of those who have lost their wives, partners, daughters, sisters and mothers to avoidable mistakes in our maternity units and to say to them that we will do everything in our power to put in place systems to ensure it never happens again. This is an incredible achievement by those in the Gallery.

We are also here to put on record the names of some of those women for whom inquests were hard fought and which found they died as a result of medical misadventure. This has happened over the past ten years and is, therefore, is very recent. Their inquests have brought the issue of maternal deaths into the public domain and given it the public attention it deserves. They are Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar, Sally Rowlette and Malak Thawley. I will also name their husbands and partners, some of whom are here today. They are Sean Rowlette, Michael Kivlehan, Abiola Adesina, Aidan McCabe, Stephen Hyland, Francis Crean, Padraic Flanagan, Praveen Halappanavar and Alan Thawley. Sally Rowlette's children, Leanne, Joseph, Abbey and Sally, are also with us today in the Gallery. Leanne Rowlette is a great singer. Members should look her up on the Internet.

We are here for women like Antoinette Pepper who died 30 years ago in St. Vincent's hospital and whose family has been repeatedly denied an inquest.

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We are here for Helen Moynihan, who died in the National Maternity Hospital in 1981. We are here for all the women whose names we do not know and for whom no inquest was ever held. We are here to make sure, happily, that it never happens again, and to take steps to ensure that no family has to go through the agony these families have had to go through. We are here to throw down the gauntlet to the HSE that we are not going to accept another family being put through this trauma or being stonewalled by a litigation obsessed health service. We need and want a health system that works for women and their families; a health system that does not compound the families' suffering by denying, defending and covering up in the face of the most devastating tragedy. This is why we need mandatory open disclosure and mandatory inquests. There is something really wrong with our health service when more is paid in damages and legal fees than on our maternity services. I am aware that some of those in authority like to talk about Ireland having a litigious culture but it is a fact that without the transparency that comes from full and mandatory open disclosure and full inquests the only way people have to get the truth and information is to go through a legal system. It should not be like that. We need transparency, we need inquests and we need recognition of the wrong. We also need lessons to be learned.

We have a responsibility to the women, to the families of the women and to the campaigners. I want to pay tribute to those campaigners, to the activists in the Elephant Collective, many of whom are in the Public Gallery today, to the 24 county councils in the State that passed motions calling for mandatory inquests into maternal death, and to all those who sent letters to the Minister and who emailed and called to keep the pressure on to get the Bill to this point. I pay particular tribute to the families. Their struggle has been extraordinary. The families are ordinary people who have lived through extraordinary tragedy. The families' dignity, persistence, dedication and strength is absolutely humbling. I am totally in awe of the families and so very glad that we are here today.

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