Dáil debates

Friday, 11 December 2015

Coroners Bill 2015: Second Stage [Private Members]

 

3:15 pm

Photo of Clare DalyClare Daly (Dublin North, United Left)
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I move: "That the Bill be now read a Second Time."

I acknowledge it is the 11th hour as we have almost reached the Christmas break but I am glad we are discussing this legislation. Earlier this week, when I thought I might not be around for a few weeks, this was the only item of business that I would have been gutted to miss. It is not that other issues are unimportant but this Bill is particularly special and getting this to the next Stage is an opportunity for us to do something important for women. I thank Deputy Joan Collins who had undertaken to stand in if I was absent today and I also thank the Government, having amended the schedule originally and taken the Bill off, for agreeing to putting it back on. I am also especially glad to hear the Minister has indicated that she will not oppose the Bill and will allow it to pass Second Stage. I am keen that we try to follow that up and get the legislation into committee because this is the culmination of a huge volume of work that has not been done by me. I am only standing on the shoulders of others. I am humbled to introduce the legislation and I am conscious that all I am is a voice and a vehicle for the efforts of others who have led the fight on this issue, many of whom are in the Visitors Gallery. They are responsible for putting the issue centre stage.

I refer to the incredible, almost unspeakable, bravery of the husbands and partners affected who had to deal with their own grief and personal loss alone and then, on top of that, had to battle to have inquests held to find out what happened to their wives and partners. I also refer to the resilience and tireless crusading by people such as Dr. Jo Murphy-Lawless and all the other educators, midwives, student midwives and birth activists who have striven to raise public awareness to make maternity services safer for women. Their efforts are reflected in this Bill. It is mad to think that almost ten years ago on 20 December 2005, the then Government approved the drafting of legislation that later became the Coroners Bill 2007.

That Bill incorporated many of the recommendations of the coroners review group in 2000 and the coroners rules committee from 2003 in order to update and overhaul the functions of the coroner, which is currently governed by the Coroners Act 1962. We all know a hell of a lot has changed since 1962 and it is absolutely unacceptable that this issue has not been addressed before now. It has been on the Government's books but there has been no progress to date, which is not good enough.

Women's lives matter and we have a chance with this Bill to acknowledge that and address inadequacies in the current system. My Bill largely takes the 2007 Bill and makes two crucial additions. The first would amend section 53 of the Act, dealing with circumstances in which a coroner must hold an inquest to include all cases of maternal deaths, and the second amends section 75(1), which covers mandatory post mortems and special examinations, again in the case of maternal deaths. This would be absolutely critical. The original Bill refers to "investigation" but, to be honest, it would be up to the coroner whether the process would go further, which is just not good enough.

This Bill is simply about triggering an automatic inquest into a maternal death, which is a death during or following pregnancy up to six weeks post partum for any hospital or maternal care unit or other location where women are under the care of an obstetrician or midwife. Why do we need this? It is an urgent matter that we enact this into law in the lifetime of this Government. The reason is best expressed in the letter written by the children of Ms Sally Rowlette to the Minister for Health, Deputy Varadkar, last year. They stated:

We miss our mum so much every day. Can you please make sure this will never happen to any other mum again and make our hospitals safe? We have to learn from these tragedies to help minimise and stop them occurring for others.

Sally's husband, Seán, and Michael Kivlehan, who lost his wife, Dhara, days after the birth of their son met the Minister, Deputy Varadkar, earlier this year but have yet to see realised any of the promised improvements they were told would be put in place. That is why this legislation is urgent.

We hear much about Ireland being one of the safest countries in the world in which to give birth but in the absence of accurate statistics, it is a groundless assertion. In 2007, two courageous obstetrics consultants pointed this out in a public letter to the Irish Medical Journal, indicating that our national maternity mortality statistics were under-reported, suffered from poor validation methods and were not reliable. That is a fact. In 2007, Tania McCabe lost her life, and she was followed by Evelyn Flanagan later that year. These were the first of the eight cases where public inquests eventually ruled that medical misadventure was the cause of death for healthy, pregnant young women. The others were Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette. We are here in their memory, battling for their families, and also as people who never knew these women. We are saying that this cannot happen to other women in 2015 and it is just not good enough.

In 2009, moves were made to collect accurate figures for maternal deaths with the establishment of the Maternal Death Enquiry. In its first report in 2012, it stated that data collection was only slowly improving and that it remained incomplete. It identified problems such as an inconsistent approach to data classification, a lack of a national approach and the need for a question on pregnancy status at time of death to be included in all coroner certificates. It also pointed out that there was incomplete engagement on behalf of many of the hospitals, particularly general hospitals with maternity units. One of the fears seemed to be that these institutions were fearful of litigation. Instead of being open, transparent and accountable to patients, they instead ran for cover and went on the defensive when families sought to ask questions and have concerns answered.

That was well articulated in some of the interviews given by Seán Rowlette and Michael Kivlehan, who spoke about counteracting sorts of cover-up when they needed full disclosure. Although their wives cannot be brought back, they do not want others to suffer in the same way. They spoke about the arrogance and incompetence that they saw in our maternity services and how they had to battle for years to get inquests. We know others never got an inquest. When I asked the relevant Minister about this earlier in the year, she said she was not really keen on the idea as it could impose unnecessary further distress on the families of the deceased. The people in the Gallery are testament to the experience that people need answers and closure; a public inquest is the only way in which to deliver that. Deaths by medical misadventure are an unintended outcome of an intended medical action. An inquest does not apportion blame or anything like it but it allows the opinion to be entered on the death certificate.

Last year, after the deaths of babies in Portlaoise, the Minister, Deputy Varadkar, correctly stated that those families had been lied to. Lying has been a persistent reality for the families in the Gallery and those which have faced the tragedy of maternal deaths. We know that has been true for a considerable period, from Helen Moynihan in 1981 to Antoinette Pepper in 1988, whose family fought resiliently to try to get an inquest into her death. They still have not achieved that goal but I put on record again a call for an inquest into her death. What all these families share is the experience when seeking answers of meeting well defended and very partial explanations. They were often told there would be internal investigations and they should not worry. They had to fight for inquests and they needed to know why healthy women who had come early and appropriately for antenatal care - all fully in the care system - had died. They would not know the answer without an inquest.

We know from inquests into the deaths of these eight women that vital information was withheld and they were often not privy to the internal investigations and reports until the HSE was ordered to produce them by coroners in public hearings. We know that although hospitals and the HSE indicated there would be changed guidance and protocols to deal with similar events in future, they were not implemented and carried through fully. That is a shocking statement and I am in no way saying it lightly. If the HSE recommendations issued on foot of the inquest following Tania McCabe's death had been made enforceable national policy, Savita Halappanavar may not have died. It is also the case in the death of Dhara Kivlehan. If her inquest had not been obstructed and delayed for four years from when she died in 2010 to the inquest in 2014, Sally Rowlette, who died in 2013 in the same hospital from the same failure, may not have died either. This is an incredible statement about a health service in 2015 but it is true. That is why it is critical that not only should allow the Bill pass today but we should get it through Committee Stage and begin to make it operational.

The Irish Maternal Death Enquiry team released its latest briefing document this week and between 2011 and 2013, there were a total of 27 maternal deaths occurring during or within 42 days of pregnancy. People were interested in the death of 88 gardaí in the history of the State, which is significant, but there have been 27 maternal deaths in two or three years, which is much more dramatic. Of those deaths, seven were classified from direct causes and of those, only three had inquests. Knowing what we do from inquests about lack of care and appropriate and timely diagnosis, it is clear we needed those other four inquests into the deaths. This could only be done properly with an automatic public inquest. We have two to three maternal deaths of all categories in Ireland every year, which is a phenomenal figure. We need to know in full why a death happened and what lies behind it.

We cannot rely on confidential inquiries because hospitals and the HSE hide behind them. That is a fact. The only way to get transparency is through accountability, with public inquests so that families get answers but also to enforce genuine accountability on the part of the HSE. Unfortunately, as matters stand, we do not have that.

All pregnant women need to know that the maternity services and the HSE will be accountable for both genuine continuity of care and an end to the fragmentation of services. They need to be able to rest assured that there will be excellent communication between doctors, midwives, themselves and their families and that there will be an to complacency and to not listening to these women and their families. We should have an international gold standard in terms of maternity care rather than rhetoric from the HSE. The idea of an automatic coroner's inquest will give families the truth, it will give transparency and it will give the wider community a way to hold the HSE to account.

Many of these conclusions are based on the outstanding work of Dr. Jo Murphy-Lawless, who is in the Gallery. These are her words. She has been a pioneering crusader on these issues and the awareness that exists in Ireland with regard to these matters would not have happened without her. I want to refer to the wonderful exhibition by the Elephant Collective that many of the women are involved in, which is very aptly titled "Women's Deaths Remembered: Picking Up the Threads, Remaking the Fabric of Care". It is based on a knitting exhibition to remember all the women who died tragically in the care of our maternity services. It involves beautiful paintings, a documentary, and a wonderful remembrance of those vibrant young women, but also a reminder of the importance of making changes for the future. They very poignantly use the name "the Elephant Collective" on the basis of the behaviour of elephants who, it appears to me, are much more civilised than human beings or than many institutions in Irish society. When an elephant gives birth, the rest of the herd surrounds her to protect her and her calf. What we are being asked to do today, in pushing this Bill, is to be that herd, in essence.

Our society has let women down. We have to be honest about that. From the Magdalen laundries to symphysiotomy to our current lack of bodily integrity in respect of abortion and to the eight women who so unnecessarily lost their lives through medical misadventure. It is not just those eight women, it is also about those others who did not even get an inquest. We must learn from those tragedies. It is that simple. We must raise awareness about this issue. We have to ensure there is an automatic inquest and vastly improved disclosure methods in terms of hospitals and the HSE reporting on tragic and adverse incidents in our maternity services. It is only by doing this that we can open them to more public scrutiny and give women in Ireland and their loved ones and families the type of care they rightly deserve.

3:35 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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On behalf of the Minister for Justice and Equality, Deputy Fitzgerald, who regrets that she is unable to attend this debate, I thank Deputy Clare Daly for bringing forward this Bill, which raises very important issues. Like the Deputy, I note the presence in the Gallery today of several people who have lost those very close to them in tragic circumstances. The Minister asked me, in particular, to express her deepest sympathy to them and the other families bereaved by maternal death for the dreadful loss that they and their children have experienced. At the outset, I confirm that the Government intends not to oppose the Coroners Bill 2015, as the Minister very much appreciates the intention behind it. The Government will be bringing forward substantial amendments on Committee Stage and I will explain why that has to be the case.

Deputy Clare Daly's Bill has two distinct elements. It contains a small number of provisions that would introduce mandatory post mortems and inquest into any maternal death. Under the Bill, this would include any woman who dies during pregnancy or within six weeks after delivery and who, at the time of her death, is receiving inpatient or outpatient care at a hospital, maternity unit or birth facility or has been discharged from one within the previous six weeks. The Bill also contains a very large number of provisions on the entire coroner system, which, in effect, reproduce the whole of the Coroners Bill 2007. The latter was presented to the Seanad on 20 April 2007 and completed Second Stage on 4 October 2007. It was subsequently restored to the Order Paper by this Government.

I do not propose to enter into a section-by-section discussion of the Bill before us. I would prefer to focus on the key issue of maternal death but I must also briefly address the overall framework for the coroner system proposed in the 2007 Bill, as the Deputy has effectively incorporated that into her Private Members' Bill. The Coroners Bill 2007 proposed a major overhaul and restructuring of the entire coroner system. For example, the current fragmented system, of some 40 different coroner districts under the responsibility of local authorities, was to be replaced. Responsibility for coroners would be transferred to the Minister for Justice and Equality, with a new post of chief coroner and a new central coroner service to provide enhanced support to coroners and to liaise with bereaved families.

Inevitably, in light of the major challenges confronting public finances, the 2007 Bill was then postponed for some years, although this Government has retained it on the Order Paper. The Minister is extremely conscious of the importance of the coroner system, and as she has indicated in replies to parliamentary questions over the last year, she already directed her Department to undertake a comprehensive review of the 2007 Bill. The aims of the Minister's review are to identify how best to deliver an integrated, reformed structure that will support coroners more effectively, within the Government's current financial possibilities; to bring the 2007 Bill up to date for legal and forensic developments, particularly to ensure full compatibility with the European Convention on Human Rights; and to put in place improved support to ensure that bereaved families receive a prompt, responsive and effective service, recognising that coroners already strive to do so within the constraints of the existing administrative framework. That review is making good progress and will continue its work into early 2016. It is absolutely clear that the 2007 Bill, and, therefore, the overall content of the Deputy's Bill, is fundamentally outdated. The Government intends, therefore, to propose extensive amendments to the Private Member's Bill on Committee Stage, to ensure that any reforms will be addressed within the detailed review that is being prepared for the Minister, because that is the best way to ensure they are effective and properly resourced.

I turn now to the principal concern of Deputy Daly in presenting the Bill, namely, to introduce a new requirement for mandatory post mortems and inquests into maternal deaths. The Minister is very sympathetic to the concerns which motivate this Bill. Every maternal death is a tragedy and, as those present here today observing our debate remind us, one with which the bereaved family must go on living. Maternal deaths tend to be complex events. It is often difficult to identify and collect quickly all the key facts, both for the bereaved family and, sometimes, for the health professionals, particularly if the mother has been transferred between hospitals in emergency circumstances. The Minister is strongly of the view that bereaved families in this situation are entitled to a prompt, transparent and sensitive response to their questions and concerns.

The Coroners Bill 2007 already proposed a legal requirement to report any maternal death to a coroner. The Minister intends to keep that proposal but she considers that there are strong arguments for examining whether an inquest should be legally required in cases of maternal deaths as defined by this Bill. Every maternal death would thus be recognised as a serious incident. A full, accurate and impartial account of the circumstances leading to the death would be given in public and would be available to the bereaved family. Mandatory inquests could help to ensure that lessons can be learned from these very tragic cases, with a view to helping maternal healthcare facilities reduce the risk of other such deaths occurring. There are, however, also some concerns that would need to be considered. One important concern is that not every maternal death raises issues requiring further investigation and in those cases, the bereaved families might be exposed to additional grief and distress if an inquest were compulsory despite their wishes. However, the Minister wishes this question to be fully examined and is sympathetic to the objectives of the Bill in this respect. This question is already being looked at within her Department's review and she wants to consider this issue further.

The Private Member's Bill could benefit from considerable amendments to ensure that it is legally valid and an appropriate instrument to ensure that the coroners system can provide the best possible, high-quality public service. I think Deputy Clare Daly might be open to that. The question of mandatory inquests for maternal deaths is a complex issue and the Minister would like to give it in-depth and thorough consideration, in consultation with the Minister for Health and other stakeholders. I assure Deputies that the Minister will carefully reflect on today's contributions and the points made as she undertakes that consideration. In conclusion, and on behalf of the Minister for Justice and Equality, I thank Deputy Clare Daly again for bringing this Bill forward, particularly as the motivation behind it is well-intentioned and commendable.

I want again to acknowledge the deeply difficult and distressing issues which are raised for those who have lost their loved ones through maternal deaths. The Minister will continue with the review she has instructed her Department to undertake. It will continue into early 2016. The Minister does not intend to oppose this Bill.

3:45 pm

Photo of Mick WallaceMick Wallace (Wexford, Independent)
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I welcome the Bill, particularly the new provisions proposed by Deputy Clare Daly to seek to make inquests mandatory in all cases in which a woman dies in the care of maternity services before, during or after giving birth. For far too long, the HSE has defaulted to defensiveness and denial when things have gone wrong. It has refused to engage with the causes of sometimes catastrophic mistakes in maternity services. It has forced families into long and exhausting fights for justice after the deaths of loved ones. By refusing to face up to and acknowledge the mistakes that have been made, the HSE is making it inevitable that more mistakes will be made. By defaulting to denial, it is prolonging the suffering of bereaved and devastated families.

As it stands, maternal deaths fall into the category known as "deaths reportable to coroner". Other reportable deaths include the deaths of children in State care or detention, deaths due to possible negligence, misconduct or malpractice, and cases of suicide. When a coroner receives notice of a reportable death, he or she will investigate it and decide whether any further action is necessary. An investigation is relatively cursory by comparison with an inquest, as it does not involve an intensive examination of the circumstances of a death. An inquest is the only mechanism by which all the circumstances of a death can be fully investigated and a verdict on the cause of death issued. Without this kind of comprehensive investigation in cases of maternal death, the same mistakes will continue to be made over again and women who should be alive may die through medical misadventure or negligence.

It is shocking that all eight inquests into maternal deaths since 2007 have issued verdicts of medical misadventure leading to death. It is inexcusable that in every case, the families had to fight tooth and nail for an inquest to be granted in the face of total intransigence from the HSE. It is devastating that the delays in granting an inquest into the death of Dhara Kivlehan may have contributed to the death of Sally Rowlette, who died in the same hospital as Dhara Kivlehan and from the same condition. If the hospital in question had learned lessons from Dhara's death, Sally may have been diagnosed and treated in time to save her. If it was standard for automatic inquests to happen in the case of every maternal death, all the women who have died through medical misadventure before, during or after childbirth in Irish hospitals might still be with us.

Transparency does matter. Owning up to mistakes matters. It literally saves lives sometimes. It is inexcusable that what we are seeking does not happen as a matter of course. We know from the eight inquests to which I have referred that information was withheld from families and that internal investigations and reports were withheld until the hospitals and the HSE were ordered to produce them by coroners in public hearings. We know that hospitals and the HSE said they would issue changed guidance and protocols to deal with similar events in the future, but they did not do so in many cases. If they did produce such guidance and protocols, they did not comply with them or did not carry them through fully. The HSE battened down the hatches in every case and hoped for the storm to pass. For the families, the storm can never pass until they get the truth.

In too many arenas of life in Ireland, there is a tendency to cover up and to deny. Ranks are closed when we raise questions in here about NAMA, the operation of An Garda Síochána and the breaches of international law at Shannon Airport. In most cases, the first port of call is to protect the organisation before protecting the public. In all of these cases of maternal death, the HSE has behaved in much the same way. Its instinct is to protect the organisation, regardless of the effect this has on patient care or bereaved families. In the past year, we have seen the HSE threaten legal action against HIQA to try to stop it from publishing a report that was commissioned following the deaths of five babies in a hospital's maternity unit. The report showed that the hospital in question had failed to learn from recommendations made in previous reports. It made it clear that there was a widespread lack of urgency in responding to risks in the hospital. It contained stories of bereaved mothers who were reprimanded for crying. It told of how one deceased baby was brought to its mother in a tin box carried on a wheelchair. The bereaved women were wrongly given the impression that their babies' deaths were isolated incidents. They were met with defensiveness, cover-ups and unfulfilled assurances. As I have said, the instinct is to cover up, deny and pretend everything is okay. It is not good enough. While the Bill can only address one aspect of the HSE's organisational instinct to cover up, we need better transparency right across the board within the HSE.

More generally, the Bill before the House will help to make Ireland more compliant with human rights values. The European Court of Human Rights has in several judgments noted the crucial role of coroners' inquests in fulfilling the State's obligation under the European Convention on Human Rights to investigate any death involving public authorities or institutions. The European Court of Human Rights has also interpreted Article 2 of the convention as providing for more extensive investigation of the circumstances of death. It has indicated that an extension of the scope of inquests is required to meet the obligations of the convention. The more information we have the better if we want to prevent avoidable deaths and improve services. These families should not have had their suffering so awfully compounded by having to fight to find out what happened to their loved ones. Things must change so that no family ever has to go through this exhausting, devastating and traumatic process again. Deputy Clare Daly's Bill will certainly help in that regard.

Photo of Pádraig Mac LochlainnPádraig Mac Lochlainn (Donegal North East, Sinn Fein)
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I commend Deputy Clare Daly on the presentation of this important Bill, which my party will be strongly supporting. The Bill seeks to ensure maternal deaths result in automatic inquests. As it stands, maternal deaths are treated as deaths which must, as a rule or practice, be reported to the coroner. However, inquests are not automatically granted in these cases. Between 2007 and 2013, eight inquests were held following maternal deaths. All eight cases resulted in rulings of medical misadventure. The Minister of State mentioned the European Convention on Human Rights, Article 2 of which clearly outlines the responsibilities of every member state in terms of its duty to investigate deaths that take place in suspicious circumstances, or in circumstances that leave them open to question. Too many families in this State have been left facing the wall of bureaucracy on their own without the required supports. I want to say clearly today that the State is profoundly failing in its responsibilities under the European Convention on Human Rights and the Government knows it.

As the Chairman of the Joint Committee on Public Service Oversight and Petitions, I have been working in co-operation with my colleague, Deputy Stanton, who is the Chairman of the Joint Committee on Justice, Defence and Equality. When both committees jointly held a day of hearings on this matter earlier this year, a range of experts made presentations and outlined the failure of this State to live up to its responsibilities. The transcripts of those hearings have been sent to the relevant Ministers, but what needs to be done is not being done.

We have been faced with Bill after Bill in recent weeks, some of which have gone through all Stages in one day. When the Government wants, it can get Bills through the Office of the Attorney General and through all Stages. Therefore, there is no excuse for not having completed and made the necessary changes to the Coroners Bill 2007 by now. There is an opportunity to deal with this now. I fully support Deputy Daly's Bill going to Committee Stage. Apparently, we will have a couple of weeks of this Dáil after Christmas. We need to reconvene and the Government needs to take that opportunity to get this issue over the line before a new Government comes into power. It is a profound failure that this issue has not been addressed.

As such inquests are not automatic, families who should be spending their energy dealing with horrific loss must instead fight for the true facts of what led to the death of their loved ones. This situation is neither rational nor just. Deputy Daly has highlighted the fact that legislation dealing with the deaths of women who give birth in hospitals is urgently needed. Sinn Féin concurs with that view. The only way in which one can improve the lives of citizens in this State is not to congratulate ourselves on things that go right, but to examine openly and without fear or obfuscation the circumstances that lead to wrong results and to ensure the tragedies referred to by Deputy Daly are not repeated.

The culture of defend and deny that is rampant throughout this State in response to a fear of litigation not only costs the State millions as a result of medical negligence cases but also prevents safer and better quality of care for patients. The Irish Medical Council states:

Patients and their families are entitled to honest, open and prompt communication with them about adverse events that may have caused them harm. Therefore you should;

- Acknowledge that the event happened;

- Explain how it happened;

- Apologise if appropriate;

-Give assurances as to how lessons have been learned to minimise the chance of this event happening again in the future.

Therefore, when patients or their families are treated with resistance and concealment of facts pertaining to a death or injury, is it any wonder they seek the path of litigation? The position taken makes little sense. In cases where information is not forthcoming, it is usually that information that is most useful in preventing the same tragic events occurring in the future. As Dr. Jo Murphy-Lawless of Trinity College has pointed out:

A maternal death casts a deep chill over the entirety of a maternity unit. Given the legal neutrality of a coroner's inquest in determining how a woman died, staff too would benefit from what we can learn through the inquest process.

I want now to highlight a related issue. Some time ago I published a Bill, to be known as "Jake’s Amendment", to amend the Coroners Act 1962 to allow for a coroner to return a verdict of iatrogenic suicide. That Bill followed from the death in March 2013 of 14 year old Jake McGill Lynch who, shortly after being prescribed the antidepressant Prozac, ended his own life using a firearm. Jake, who was diagnosed with Asperger’s syndrome, was given the antidepressant drug, despite research stating that the drug has no benefit for children with Asperger’s and despite the emerging evidence of harm. In the midst of their grief, Jake’s parents had come to understand that their personal tragedy was one that has been shared by thousands of families whose loved ones have died as a result of antidepressant induced suicide.

Jake’s parents wanted the Coroners Act to be amended in order that a coroner could return a verdict of iatrogenic - medically induced - suicide where such is the case. This is an issue that must be highlighted. A verdict of suicide returned in accordance with the provisions of the Act of 1962 must be differentiated from a verdict of iatrogenic suicide. Iatrogenic suicide is the ending of one’s own life where the effect of medical treatment undertaken by the deceased, including any prescribed medication, is the primary cause of such an action.

My Bill is in the system, but as the system here is a lottery, it is the luck of the draw whether it will ever make it into the House. This is frustrating, as I have repeatedly called for it to be taken. Therefore, when the Government is considering the Coroners Bill 2007 and addressing the issues raised by Deputy Daly today, I urge it to look also at the issue of iatrogenic suicide. In the case I mentioned, the coroner made a finding that gave some comfort to the family. One hopes lessons will be learned from that. I urge the Minister of State and his officials to take note of that when they consider these issues.

The Coroners Act of 1962 is no longer fit for purpose and should have been repealed and replaced with an amended version of the Coroners Bill 2007 as a matter of priority. In the amended version of the 2007 Bill, there should have been a comprehensive list of verdicts open for a coroner or a jury, as the case may be, to return. This list should have contained provision for verdicts such as that mentioned by Deputy Daly or me today.

Sinn Féin supports and commends Deputy Daly’s legislative proposal. It makes sense for families suffering tragic loss, in the context of preventing the recurrence of such tragedies, and of reducing traumatic and financially prohibitive legal actions.

3:55 pm

Photo of Seán FlemingSeán Fleming (Laois-Offaly, Fianna Fail)
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On my behalf and on behalf of Fianna Fáil, I support Deputy Clare Daly on bringing forward this legislation, the Coroners Bill 2015. Essentially, the Bill focuses on one issue, the need for an automatic inquest into all maternal deaths. We should all be ashamed that the Coroners Bill 2007 has been sitting on the shelf for so many years without having been completed. It is urgent that it is completed, although it probably also needs to be updated and modified.

Many people listening to this debate might wonder what we are talking about. When we talk about maternal death, we are talking about the death of a mother during pregnancy or within six weeks of giving birth. This has been spelled out, but not everybody knows what we mean by maternal death. I thank Deputy Daly for bringing forward this legislation, and I hope it gets to Committee State as soon as possible with a view to enactment in legislation as quickly as possible. Fianna Fáil will support that.

We all have personal experience of the issues we discuss and that is often what makes us good legislators. We are not normally here on a Friday afternoon and are usually out in our constituencies meeting people and dealing with their personal experiences. Much of what we say here is based on the views of the people we meet, which we must reflect. I am not aware of many maternal deaths in my immediate area, but I have some experiences of relevant issues. One case I am familiar with concerns a similar issue, the death of baby Mark Molloy in the maternity unit of Portlaoise hospital. In that case, the parents were lied to by the HSE and they had to fight hard for an inquest. Eventually, they got an inquest, but had to fight on again and again because the system here is geared to protect those in the system. It is not geared to protect the citizen.

Baby Mark's parents were not told the truth and senior HSE management covered up his death. I have often wondered whether it is a criminal offence to cover up a death. I do not know, but I have asked the question several times and have said the issue should be examined. I believe those in the HSE who covered up deaths in situations such as this are not fit for office. Their actions should be examined. It is not right that people can cover up and deny responsibility for a death and pretend it did not happen. They try to explain it away and hope the people asking questions will go away. Thank God that many parents fight for the truth in these situations.

I also know of a mother who was giving birth in Portlaoise hospital but who had to be transferred urgently by ambulance to the Coombe hospital in Dublin. Halfway there, she deteriorated and had to be taken to Naas hospital. Thankfully, she survived. The reason she was brought to Naas was to save her life. There was no maternity unit in Naas hospital so it was not to save the life of the child. She spoke to me subsequently about her experience saying that she could not get information on what had happened. This is the nub of what is wrong. People know mistakes have been made but refuse to admit the truth and try to cover it up.

Perhaps they feel they will be embarrassed if the truth comes out and that they will not look good, so they want to protect themselves and protect the organisation and hope things will go away. Telling the truth would solve the anguish of many parents in those situations. It does not correct what went wrong but it is important to get to the truth. The withholding of the truth is a double injustice for many of the families concerned.

An additional flaw in the way the situation is structured within the HSE in recent times is that the State Claims Agency manages all the legal defence cases on behalf of the State. There is now an absolute separation of the settlement of a case by the State Claims Agency from the people who were involved when the incident occurred. Nobody in the HSE cares because once cases go to the State Claims Agency it is off the books of the HSE and it has nothing to do with it anymore. In some cases of children who have suffered catastrophic injuries at birth, the case is settled in two years or it could even be seven years. That time lapse is causing further problems because lessons are not being learnt. Too many internal private reports within the HSE are not being shared. People are embarrassed and they might try to do something in one hospital but the information is not being shared. That is a complete breach of governance.

As has been said about other organisations, it is the first function of the HSE to protect the HSE. Anyone who runs into difficulty with any section of the HSE will find that once senior management gets involved there will be a clampdown on information and the first instinct is to protect the HSE. That has happened in several organisations. It happens in local authorities, education and training boards and right across the State. It is probably human nature that people react to protect themselves from an allegation or accusation but that should not be the case. People want the truth more than anything else. That is the reason we must take this matter out of the hands of those who currently deal with it to ensure there is an automatic inquest in all those situations carried out by somebody utterly independent of the organisation where the incident occurred. When one has a complaint one is always told that one is an isolated case and that it is the first time it ever happened. Everybody can empathise with that nonsense and that standard line from many organisations.

A confidential maternity death inquiry based in UCC was carried out which showed an increase in the number of maternal deaths in the 2010 to 2012 period. The report showed also that the number of maternal deaths in this country has risen sharply and the pregnancy-related death rate is now higher here than in the United Kingdom. The rate of maternal death based on hospital reports and other sources is four times higher than the official figures gathered by the Central Statistics Office from death certificates. That says it all. Official Ireland records deaths in a certain way but when one digs deeper one will find that the truth is different. I am being hard on many public organisations but, unfortunately, the evidence of that single statement proves that what official Ireland records is not the truth or the full story and it is part of a cover up. People must accept that.

There were 38 recorded maternal deaths between 2009 and 2012. Some of them may have been directly due to obstetric causes while others were caused due to pre-existing conditions and other such issues. The number is very high. We owe it to Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette who all died of medical misadventure, as determined by inquest. In those situations 14 children lost their mother and the families had to fight to get to the truth. People should not have to fight to get to the truth. That should be basic and endemic to every organisation. That is the reason the legislation is required, if for no other reason.

I support the passage of Deputy Clare Daly’s legislation. We should have dealt with the Coroners Bill 2007 long before now. I hope there is time to deal with it. The Minister of State, Deputy Simon Harris, has seen how quickly we can deal with legislation. This is the sixth separate item of legislation I have dealt with in the House today. Four of them were completed in two hours and a number of items were guillotined. Deputies were able to come to the House and in a guillotined debate lasting less than two hours approve a budget of €369 million for the next three years to run the Oireachtas. That was no problem. The House can dispose of legislation within hours if it chooses to do so. We have had four examples of the Government guillotining legislation. It is possible if we want to get something done. Christmas is coming. We are near the end of our term. We can deal with legislation and dispose of it following two hours of debate. This is the sixth item of legislation I am dealing with today but, unfortunately, this Bill is not being completed today: unlike the first four, it is being shoved off to a committee. I ask the Government to show the same sense of urgency in getting the Bill through Committee, Report and Final Stages in the next week as it has shown in the first four legislative items that were guillotined through the House today.

4:05 pm

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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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.

4:15 pm

Photo of Seán KyneSeán Kyne (Galway West, Fine Gael)
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I welcome this legislation from Deputy Clare Daly. We have often been told in other debates that our maternity services are the safest in the world and, clearly, in the majority of cases, they are, but when deaths occur, they are highlighted very often on television and in court proceedings. Coming from Galway, we all know about the tragic case of Savita Halappanavar in the very recent past.

This seems to be a very sensible Bill, and I welcome the Government's support for it, but what could be a simple change to the existing Coroners Act is being delayed because of the welcome necessity for a complete overhaul of the entire coroner system. That is regrettable, because an automatic inquest in the case of maternal deaths, as outlined in Deputy Clare Daly's Bill, seems very sensible and something that should be done automatically.

I know that a complete overhaul of the coroner system is being examined. I have been led to believe there will be an increased emphasis on delivering leaner, better integrated and more customer-focused public services. I will address better integrated and more customer-focused public services in respect of Part 7 of the Bill, which concerns the conduct of an inquest. Section 47 states that:

A coroner shall, whether by post or such other means as he or she considers suitable, arrange for the notification of any or all of the following persons—(a) a family member of the deceased,

(b) any witness whose presence is required, and

(c) any interested person of whom the coroner may be aware and who, in the opinion of the coroner, ought to be notified, at least 14 days before an inquest is to be held, of the date, time, place and subject of the inquest.

I want to speak about this not in respect of maternal deaths but in respect of a particular case.

To protect the privacy of the individuals involved, I will not name names but I want to highlight the situation that arose. I discussed the matter previously with the former Minister, Deputy Shatter, and the Minister, Deputy Fitzgerald, at an internal meeting. A constituent came to me - we will call her Mary - who had lost her mother. Her father had passed away previously and she had no siblings. Her mother died at home, alone in a town some miles away from Mary. Like any death, there was the grief and everything that goes with it. There was an autopsy and pathology examinations. What followed that was a very long period of waiting for the pathology results to come through. I have checked with colleagues here who are doctors and they say normally it should not take more than a couple of months. This went on for months and months. Meanwhile, I had contacted the coroner, who was very helpful but said the pathology reports were still awaited and that an inquest could not be ordered until they arrived. Mary herself was on to the coroner and it was the same story. The coroner eventually rang Mary to say they were still waiting for the pathology report. That was coming up to a year after Mary's mother's death.

Subsequently, a friend of Mary happened to be in town one day and by chance met Mary's mother's carer. The carer expressed shock that Mary had not been at the inquest into her mother's death. Mary was not at the inquest because she had not been notified of it. She did not have a clue that inquest was going ahead a year after her mother's death. This put Mary into another period of shock and grieving as she dearly wanted to be at the inquest. She had things to say, which I will not get into, about care and mental services in particular. Further to that, when she went looking for a copy of the inquest report, she was charged for it. She subsequently had the charge overturned on appeal but it was a further annoyance. Mary was deeply upset that while she was at work one day an inquest into her own mother's death was taking place and she did not have a clue about it. When she contacted the coroner subsequently, she was told the coroner had notified a local garda in the town. Mary did not live in that town and the garda did not have a correct number for her. He stated that he told Mary's uncle about it but Mary's uncle did not tell Mary. They may not have been getting on or he may have felt it would have been better that she not attend the inquest. He may have been trying to protect her or something of that nature.

In any reform of the legislation relating to coroners and the Coroners Service, there needs to be a better system. No way should an inquest into a death take place when the next of kin does not know about it. If the person does not go that is his or her own business but to not even know about it is scandalous. It caused Mary grave upset. In section 47 there needs to be a specific reference to something like registered post or whatever in order to ensure the next of kin knows about the date and place of an inquest. When I highlighted this to the former Minister, Deputy Shatter, and his successor, Deputy Fitzgerald, they both felt it should be examined. I want to put the issue on the record of the Dáil, particularly for the people from the Department who may be involved in a future Bill.

4:25 pm

Photo of Simon HarrisSimon Harris (Wicklow, Fine Gael)
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I thank Deputy Clare Daly and all those who contributed to the debate about these very important issues. I reiterate that it is the Minister's intention that the Government will not oppose this Bill on Second Stage. The Minister very much appreciates the intention behind the Bill and what the Deputy is trying to achieve.

As the Minister has asked me to indicate, the legislation will require substantial amendment on Committee Stage for the reasons she has outlined. From my reading of all the material, I think it boils down to two issues: the ongoing review that she has in the Department of the Coroners Service to make sure we can modernise it and get it right; and the issue of mandatory inquests, to make sure there is not any unintended consequences whereby a bereaved family might find itself having to participate in an inquest which it may not wish for in certain circumstances. They are the two points I would make in the context of the Minister not opposing this Bill.

A number of contributions from Deputies confirm and underline the important contribution made by the coroners system and the value placed on it by bereaved families. That says a great deal about its value. Deputy Mac Lochlainn referred to transcripts of the joint committee hearing which considered the importance of ensuring the coroners system complies with the Convention on Human Rights. After that hearing, the Minister requested copies of the transcripts and they are being fully considered in the context of her review.

As I have already indicated, the underlying issue is the need to make sure we have a comprehensive review of the coroners system which gives a solid financial and administrative basis to that system in order that it can be modern and fit for purpose. This is an issue which the Minister, Deputy Fitzgerald, has signalled is a priority for her. It needs a well-thought-out, revised framework for coroners and needs to be matched by appropriate financial resources also. The Minister's review aims to ensure a solid foundation to modernise the coroners system and to ensure that the quality of service is in place that Members of this House and, most particularly, bereaved families would wish for. I can inform the House on behalf of the Minister that the review is already well progressed. The Minister wants me to reassure Deputy Daly and all Deputies who have contributed that it will take full account of all the important issues which have arisen today.

On Deputy Boyd Barrett's point about transparency and consent in respect of organ retention at post mortem examinations, this is a very important issue. I can confirm to the Deputy that it is being considered in the context of the Minister's review of the Coroners Bill. I will certainly bring to the Minister's attention the specific, very difficult and sensitive case the Deputy raised.

I want to express the Minister's appreciation to Deputy Clare Daly for bringing the Bill forward. I confirm that the important issues that have been raised will be given in-depth consideration and will be integrated into her review of the coroners legislation. In particular, I thank the bereaved families who have been here to observe our debate. I thank them for their presence, which reminds all of us of the absolute importance of getting this right.

The Government does not oppose this Private Members' Bill, subject to the need for amendment as I have already outlined, to ensure that it will be legally valid and that it will lead to the effective outcomes I am sure Deputies on all sides wish to see.

Photo of Clare DalyClare Daly (Dublin North, United Left)
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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.

Question put and agreed to.