Dáil debates

Wednesday, 19 September 2018

Coroners (Amendment) Bill 2018: Second Stage

 

6:35 pm

Photo of Mary Mitchell O'ConnorMary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I move: "That the Bill be now read a Second Time."

On behalf of the Minister for Justice and Equality, Deputy Flanagan, who very much regrets he is unable to be here in person, I am pleased to have this opportunity to move the motion regarding Second Stage of the Coroners (Amendment) Bill 2018. The Bill makes a series of amendments to the Coroners Act 1962, in a far-reaching and important modernisation of our coronial law.

First, the Bill will significantly strengthen and clarify the powers available to coroners in the reporting, investigation and inquest of deaths. Second, it responds to the Private Member’s Bill brought by Deputy Clare Daly regarding maternal deaths, and addresses similar concerns that have arisen in some perinatal or infant deaths. Third, it will provide for a wider scope of inquiry, where necessary, at inquest, and makes a range of other changes that will enhance our compliance with our obligations under the European Convention on Human Rights.

On behalf of the Minister, I wish to acknowledge the contribution of Deputy Clare Daly, through her earlier Private Member’s Bill, on the issue of maternal deaths. Arising from her Private Member’s Bill, significant work was undertaken in the Department of Justice and Equality to introduce a suite of reforming legislative provisions in addition to her proposals. The Minister, Deputy Flanagan, is deeply committed to these reforms and he has informed me that Deputy Clare Daly and her office kept in very regular contact with his Department to ensure that this Bill reached the floor of the House at the earliest opportunity. I again thank Deputy Clare Daly on behalf of the Minister, Deputy Flanagan, for her steadfast commitment to these issues and for her work.

Deputy Clare Daly's Bill addressed the findings of inquests and inquiries in a number of high-profile recent cases that have caused great public unease. Some maternal deaths occurring in hospitals, which should have been reported to coroners - because they raised issues of medical error and were "unnatural deaths" under the Coroners Act 1962 - were not so reported. I am conscious that these cases remain live for many of the people present tonight. Bereaved families and, in some instances, even coroners, experienced considerable difficulty in obtaining basic information that should have been provided to them. This was, and is, not acceptable.

Deputy Clare Daly’s Bill received broad support from all sides of the House and was not opposed by the Government. The Government Bill I am introducing tonight accordingly incorporates all the amendments sought by the Deputy regarding maternal deaths.

This Bill will require mandatory reporting to a coroner, mandatory post mortem examination and mandatory inquest in all cases of maternal or late maternal death. It also will extend the legal aid scheme for family members at certain inquests to cases of maternal or late maternal death. The coroner will have a discretion to make an exception to mandatory inquest, after consulting with the family, if having regard to specified conditions, including the views of the family, the coroner is satisfied that the death is a natural one.

In addition, the Bill provides for mandatory reporting to a coroner of all stillbirths, intrapartum deaths, and infant deaths. As I mentioned, this requirement responds to similar public concerns, which have arisen in a number of cases regarding perinatal and infant hospital deaths. However, we are not proposing mandatory post mortem examination or inquest in these particularly sensitive cases. Post mortem examination and inquest in such cases will remain, as currently, at the coroner’s discretion. The wishes of the bereaved parents are a key consideration for coroners in such cases.

These provisions fit logically into the overall purpose of the Bill, which sets out in a more clear, comprehensive, specific and stringent manner the legal framework for reporting and investigation of certain deaths.

Section 6 specifies the situations where a death must be reported to the coroner. They include any death which appears to be violent or unnatural, where the circumstances may in the public interest require investigation or simply where the death is unexpected and the cause is unknown. In addition, the Bill inserts a new Schedule setting out specific types of death which must be reported to the coroner, including, for example, all maternal or late maternal deaths and all infant deaths. Section 6 also sets out clearly what persons are legally responsible for reporting a mandatory reportable death to the coroner, and provides for updated penalties where this is not done.

In a limited range of situations, which I will outline shortly, the Bill provides for mandatory inquiry or mandatory inquest by the coroner. I should emphasise that in the vast majority of other cases, mandatory reporting does not result in a post mortem examination or an inquest. Most reported deaths are cleared by the coroner, but mandatory reporting does ensure that in situations of concern or doubt, coroners have the necessary information to assess whether the death is one that requires further inquiry.

Regarding post mortem examination, section 16 inserts a new section 33A which sets out in a clearer, more comprehensive and more stringent manner a limited range of situations where a post mortem examination is always required. These include deaths which following inquiry by the coroner, appear to be violent or unnatural, or where the death is unexpected and the cause is unknown. They will also include, more specifically, any death occurring in State custody or detention, any maternal death or late maternal death, as well as certain deaths where a post mortem examination is a statutory requirement. The coroner retains a discretion to direct a post mortem examination into other deaths, under proposed section 33.

Regarding inquests, section 7 amends the 1962 Act to expressly set out the situations where an inquest is already required by law - including where the death appears to be violent or unnatural, or to have occurred unexpectedly and from unknown causes, or in certain situations where an inquest is a statutory requirement - and specifies that, in addition, an inquest must be held into any death occurring in State custody or detention, and into any maternal death or late maternal death. The coroner retains a discretion to direct an inquest in other cases under section 8.

The Bill introduces other important reforms. It strengthens the coroner’s powers to summon witnesses to an inquest, to direct production of relevant documents or to enter premises and take possession of relevant records. It updates sanctions for a person obstructing an inquest. It also requires family members to be informed regarding post mortem examinations or inquests.

I wish to inform the House that, on behalf of the Minister for Justice and Equality, Deputy Charles Flanagan, the Government has agreed to priority drafting of a number of further amendments, which the Minister intends to bring forward on Committee Stage. Subject to the advice of the Attorney General these will include: providing a statutory basis for a coroner to inquire into a stillbirth where there is cause for concern, for example, arising from matters raised by the bereaved parents; permitting a coroner to seek directions from the High Court on a point of law relating to his or her functions; providing a power for the coroner to direct a hospital or other health institution to make available relevant medical records of a deceased person for the purposes of the post mortem examination; and empowering the Minister to make regulations, which will be developed together with the Minister for Health and relevant professional organisations, to guide the best conduct of a post mortem examination for coronial purposes, and the proper storage and ultimate disposal of human tissue or organs removed for the purposes of the post mortem.

Many of the Bill’s provisions build on an extensive review by the Department of Justice and Equality of the Coroners Bill 2007, which also proposed to modernise and strengthen coroners’ powers but had become, in some respects, outdated. The 2007 Bill also provided for a major administrative restructuring of the coroner system. Due to the major challenges then confronting public finances, this aspect of the 2007 Bill was not progressed following Second Stage in the Seanad, and now needs significant updating. We must, however, continue to examine the optimum organisation of the coroner service. Further elements of the existing law and structures will require significant improvement.

I will now address the main provisions of the Bill. Section 1 is a standard provision stating that the principal Act referred to in the Bill is the Coroners Act 1962.

Section 6 of the Bill inserts into the principal Act a new Part IIA on reporting of death. It consists of two proposed new sections. Proposed section 16A sets out comprehensively the general types of deaths that must be reported to coroners. It should be read in combination with the new second schedule contained at section 28 of the Bill, which sets out a list of concrete examples of mandatory reportable deaths. This list expressly includes any maternal death or late maternal death and any death of a stillborn child, a death intra partum or an infant death. There is a power for the Minister to amend the list of reportable deaths by statutory instrument.

Proposed section 16B sets out comprehensively the various persons who are under a duty to report a mandatory reportable death to the coroner. Reporting does not mean the death would automatically be subject to a post mortem examination or an inquest. A doctor reporting the death to the coroner must indicate whether he or she is satisfied, in the circumstances, to certify that the death was due to natural causes. Where no cause for concern arises, such a certificate is sufficient under the Coroners Act. The section also updates the penalties for failing to report a reportable death.

Section 7 updates section 17 of the principal Act to provide that an inquest is mandatory if the person has died in State custody or detention, and also in all cases of maternal death or late maternal death. Section 7 also provides for the possible exception to mandatory inquest in maternal death cases, subject to a number of specified conditions. The coroner must be satisfied that the death was a natural one and there are no matters of concern requiring inquest, after consultation with the bereaved family and taking account of four specified conditions, including the outcome of the post mortem examination, the family’s views and whether sufficient information has been provided to the coroner regarding the death.

Section 8 amends section 18 of the principal Act to provide that the coroner has discretion to inquire into the circumstances of death and if the coroner thinks proper, to hold an inquest if a medical certificate of the cause of death has been provided but the coroner considers that the certificate is not completed in a satisfactory manner.

Section 9 is a significant provision, which extends the scope of the inquest to include establishing "the circumstances in which the death occurred". This is a key issue in certain inquests, for example, those occurring while the deceased was in State custody or detention, and for strengthening our compliance with the European Convention on Human Rights. It will remain the position that an inquest does not make any finding of civil or criminal liability.

Section 10 requires the coroner to give at least 14 days’ notice to family members and interested persons regarding the holding of the inquest. Section 12 modernises the current provision for identifying the body of the deceased person.

Section 13 of the Bill amends section 30 of the principal Act, to delete the restriction that an inquest shall be "confined to ascertaining the identity of the [deceased] person ... and how, when, and where the death occurred”. This change flows from the new provision at section 9, widening the scope of the inquest.

Section 14 amends section 31 of the principal Act to include reference to the findings made at inquest, in that section’s prohibition of censure. Section 16 replaces sections 19 and 52, and amends section 33, of the principal Act concerning post mortem examinations directed by the coroner. It introduces four new sections, 33A to 33D, providing for: a modern process for directing the post mortem examination; a requirement for information about the post mortem examination to be given to a family member; a more detailed statutory framework where there is a mandatory post mortem examination; the making and reporting of a post mortem examination by a pathologist; and a new power for the coroner to direct a further post mortem examination of the body of the deceased, if the coroner thinks necessary.

Section 17 amends section 37 of the principal Act to provide that if a witness fails to attend the inquest without reasonable excuse, the coroner can seek a High Court order directing the witness to attend.

Section 18 amends section 38 of the principal Act. It will empower a coroner to direct a witness to reply on oath or affirmation, or to answer a question, and to direct a person to produce to the inquest documents or objects in that person’s possession or control. It also allows the coroner to seek a High Court order that a person comply with the coroner’s direction.

Section 20 amends section 40 of the principal Act to remove the requirement that the coroner must sit with a jury in every road traffic death case. This change has long been sought by coroners. Currently, the jury requirement even applies in straightforward cases where no other vehicle is involved. Coroners advise that it is increasingly difficult to empanel juries for such a large volume of cases. The coroner would instead keep the discretion to empanel a jury in any road traffic case, where appropriate.

Section 22 provides a significant new power for the coroner, acting under a warrant from the District Court, to enter and inspect premises and to take copies or possession of any document or material relevant to the inquest.

Section 23 is a new provision whereby the coroner may obtain advice and assistance from an expert, if he or she considers it necessary, on a particularly specialised subject relative to the death.

Section 26 extends the scheme of legal aid in the principal Act for a family member of the deceased at inquest, introduced in 2013 for certain categories of deaths, to cases of maternal death or late maternal death.

Section 27 inserts a new provision whereby if a body corporate commits an offence under the Coroners Act, its officers may also be personally liable if they consented or connived in its commission.

Section 28 provides for the new Second Schedule, which sets out for the first time in statutory form a specific and detailed list of concrete examples of deaths that must be reported to a coroner.

The proposed changes to the law in the reporting of deaths will ensure clarity for responsible persons, including hospital authorities, and will support the development of transparent and accountable oversight for checking and investigating certain types of death. Most importantly, they will support timely and transparent provision of information by health and other authorities to bereaved families. The Minister hopes that, with the co-operation of all sides, we can facilitate the Bill's swift passage. I commend the Bill to the House and thank the Acting Chairman for the extra time.

6:55 pm

Photo of Eugene MurphyEugene Murphy (Roscommon-Galway, Fianna Fail)
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I allowed the Minister of State to run over for a few minutes. Given what she was describing, it was important to let her conclude.

Photo of Fiona O'LoughlinFiona O'Loughlin (Kildare South, Fianna Fail)
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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.

7:05 pm

Photo of Louise O'ReillyLouise O'Reilly (Dublin Fingal, Sinn Fein)
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I join with Deputy O'Loughlin in thanking Deputy Clare Daly, who I know had her own Bill covering mandatory inquests for maternal deaths. I believe in many ways that her work has forced this onto the Government's agenda. I hope that Deputy Clare Daly is happy with this legislation and that the families who have suffered with regard to maternal death are happy with it too. We in Sinn Féin believe it is incredibly important that the remit of inquests is extended to look beyond the medical cause and into the circumstances leading to the death. Issues relating to deaths can be tragic and it is vital that a coroner can look at these matters holistically if the situation necessitates it. I am glad that this Bill will eventually extend the powers of the coroner when requesting witnesses and evidence and allow for questioning if required. I feel that the powers this Bill gives to the coroners are proportionate to the job they have to do, especially in cases where a thorough investigation is needed, such as in the case of a violent death or medical misadventure. In such cases, as we have seen many times before, such as in the cases of maternal deaths and others, coroners' powers have proven to be ineffective in investigations. This Bill seeks to gives the coroner powers of warrant, of search and seizure of documents, and also penalises those who refuse to co-operate with inquests. I am glad to see that mandatory reporting to the coroner will be extended where cause of death is unknown and if deaths are somewhat suspicious or unnatural, such as where a death has occurred in a violent or unnatural manner or by unfair means, by misadventure, or in other areas.

As stated at the outset, this Bill responds to Deputy Daly's Bill introducing mandatory inquests in all cases of maternal death or late maternal deaths, and extends legal aid to family members of the deceased. As it currently 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. It is the duty of the State 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 any supports. However, if we are to correct the situation and ensure there are mandatory inquests, then we must also address the failures which lead to the need for inquests. For instance, Ireland has the lowest number of consultant obstetricians per 100,000 women in the OECD. That is one consultant obstetrician for every 597 births per annum. To illustrate how poor the service we provide to women is, the comparable rate in Scotland is one obstetrician for every 268 births.

The shortcomings in maternity services are numerous and have directly led to heart-rending incidents involving mothers and children, including in some cases tragic death. As legislators, we must acknowledge that while it is right to ensure there are mandatory inquests in the event of maternal deaths, we must also act on the national maternity strategy and other relevant measures. The national maternity strategy has no statutory underpinning and huge swathes of it have not been implemented. We must also address the issues while ensuring there are mandatory maternal death inquests. However, it is unfortunate that the Bill does not appear to facilitate what has become known as Jake’s amendment. That would bring about a change in coroner legislation that my colleague Senator Pádraig Mac Lochlainn has been advocating for many years. In 2013, 14 year old Jake McGill Lynch was prescribed the antidepressant, Prozac. He ended his life using a firearm. Jake was diagnosed with Asperger's syndrome, and 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. The coroner in Jake's case rejected a suicide verdict. That was due to an email that Jake wrote 24 hours before he took his own life. When writing to a friend he conveyed his concerns about the medication he was taking, and said that he was feeling worse because of it. The Bill Senator Mac Lochlainn introduced some years ago proposed to amend the Coroners Act in order that it would be possible to return a verdict of iatrogenic suicide, which is essentially suicide brought on by side effects of prescribed medication. Despite many assurances to Jake's family from Ministers for Justice and Equality, the Bill does not cater for the measures they wish to see included. Sinn Féin will submit an amendment on Committee Stage to introduce the measure.

That will not be the only way in which we will seek to strengthen this legislation. I am sure many will agree with us that we should include a provision to provide a statutory basis for a coroner to inquire into a stillbirth where there is cause for concern, for example, arising from matters raised by the bereaved parents. We also believe it is essential that this legislation provides for the Minister to make regulations on the proper storage and disposal of any material removed for the purposes of a post-mortem examination, including return to a family member for disposal where requested and appropriate, and to provide power for the coroner to direct a hospital or other health institution to make medical records of the deceased person available for the purposes of a post-mortem examination. Those are just a number of areas in which we will seek to be constructive and to strengthen the legislation.

I ask the Minister to look at an issue before Committee Stage to see if there is scope for it in this Bill. While it might be the case there is not, we wish to have the issue examined. I refer to a situation whereby the family of missing persons would be allowed to deal with any immediate financial issues for missing persons, and to allow a family to apply for a declaration of presumed death to a coroner or the Circuit Court. That is a very sensitive issue. My colleague, Deputy Pearse Doherty, introduced a Bill in the Dáil entitled the Civil Law (Missing Persons) Bill. The Bill aims to provide for the effects in civil law of persons who are missing, including arrangements for interim management of a missing person's property, and to provide for the civil status of a missing person where the circumstances of his or her absence leads to a presumption of death. I may correspond with the Minister in writing on the issue to ascertain if it will be possible for such a measure to be included in the Bill.

Overall, Sinn Féin supports the aims and objectives of the Bill. I again thank the many Deputies who in one way or another have been raising issues concerning inquests into deaths in the State for many years. This legislation is the result of their tireless pursuit of justice on behalf of many bereaved families.

7:15 pm

Photo of Clare DalyClare Daly (Dublin Fingal, Independent)
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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.

7:35 pm

Photo of Pat GallagherPat Gallagher (Donegal, Fianna Fail)
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The next slot is the Rural Independents. I call Deputy Michael Collins, who is sharing with his colleagues.

Photo of Michael CollinsMichael Collins (Cork South West, Independent)
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I welcome the opportunity to contribute to the debate and I thank Deputy Daly for her work on the Bill.

The purpose of the amendments is to clarify, modernise and strengthen the legal powers of coroners regarding the reporting of deaths and the conduct of post mortem examination and inquests. I support that going forward.

The death of a loved one can be a deeply distressing time. It has been brought to my attention that when an Irish person dies abroad, his or her death cannot be registered in Ireland. That is heartbreaking for the families and loved ones of the deceased, and I sympathise with any family left in that position. That is such a difficult time for the family, and we need to consider ways of supporting bereaved families and allowing for these deaths to be registered in Ireland. According to my information, registration of the deaths of Irish people who have died abroad is short of being resolved and has cross-party support. Why has this not happened? This is an urgent issue that needs to be looked into.

When a person passes away in Ireland, this Bill retains discretion for the coroner, having consulted family members of the deceased, to hold an inquest into the death. If the coroner is satisfied, taking account of the specified matters, including the views of the family members, that the death was natural, an inquest will not be needed.

In the cases where an inquest is required, it should be carried out in a timely and efficient manner. Having spoken to some of my constituents who have relayed their experiences to me, I know these families can have problems receiving farm payments, etc. if the farm is in the bereaved's name until the inquest is completed. It is important, therefore, that strong supports are put in place for such families.

This Bill further provides for mandatory reporting to a coroner of a stillbirth death or an infant death. I have 100% sympathy for any parent who loses a child and the Bill should not place an additional burden on grieving parents at such a difficult time. I ask that this part of the legislation be examined and implemented in a way that will not cause further distress to grief-stricken parents.

I welcome that the Bill will make provision for information to be provided to a family member of the decreased. It is important that families of the decreased be kept informed during this difficult time.

I welcome also that the Bill will widen the scope of an inquest from investigating the proximate medical cause of death to establishing the circumstances in which the decreased died. It will provide new powers for a coroner to enter a premises with a warrant to inspect a copy or seize documents required for a coroner's inquiry into the death of a person and it will direct a witness to answer questions at an inquest.

Overall, I support the amendments in the Bill but stress that they need to take into account the difficulties of the families, the loved ones and the bereaved. These amendments should help to support people who have been bereaved.

Photo of Michael HartyMichael Harty (Clare, Independent)
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I am grateful for the opportunity to contribute to the debate. Mandatory reporting and having automatic inquests on all maternal deaths should be enshrined in law. Very shortly following my election to this House, I met a lady in Ennis, Ms Martina Hynan, who brought to my attention that all maternal deaths did not require a mandatory inquest. I was quite shocked to hear that. I worked as a junior doctor in the Coombe hospital and if a maternal death occurred in that hospital it was taken seriously by the medical and nursing personnel, who viewed it as a failure on their part that somebody would die in the maternity services. I understood the internal inquiries led to inquests at a later date. I was quite shocked to find that was not the case.

Martina Hynan is an artist who is part of the Elephant Collective, which is a multimedia expedition that travels around Ireland. It commemorates the deaths of those who died in our maternity services and tries to heighten awareness of those deaths. I was impressed by her. I also saw Anne Marie Green's documentary, "Picking Up the Threads: Remaking the Fabric of Care", again highlighting the issue of those who die in our maternity services or shortly after their deliveries.

The Bill mentions indirect maternal deaths, direct maternal deaths and late maternal; it covers all aspects of care. It is shocking that, in 2018, we not have automatic mandatory reporting. Those ladies, and men, who have campaigned tirelessly for this legislation visited county councils throughout the country.

Deputy Clare Daly has mentioned many councils - Clare, Sligo, Donegal, Wexford and probably many others - that have endorsed the campaign to have mandatory inquests on all maternal deaths. I know Deputy Daly does not want to be thanked but we Rural Independents Deputies generally end up speaking after her and we do want to thank her for all the work she has done in this regard and in many other campaigns. It is very important that this aspect of the Coroners (Amendment) Bill is taken seriously. If amendments need to be made to it, they should be made. It is absolutely essential that women get proper care but also that the families of those women who died, their husbands, parents and the children who were left behind, get answers on what the circumstances were in respect of their deaths. That does not in any way imply that there was any negligence in those deaths but it is very important that they are properly investigated so that those in caring roles can learn from what happened to prevent it from happening in the future.

I commend the Bill to the House and hope it makes a rapid passage through the Oireachtas.

7:45 pm

Photo of Danny Healy-RaeDanny Healy-Rae (Kerry, Independent)
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I am glad to get the opportunity to talk on this very important Bill and also to thank Deputy Clare Daly for her input and her long-standing work on this matter. The coroner services, which are operated by the local authorities, are in many instances the final verification of what happen to a family's loved one and on all occasions it is a very sad time for families. So many families have to endure and wait for this inquest which in some cases takes a very long time. I would ask that going forward these inquests be expedited. If they go on for a long time while families are getting back and starting to live without their loved one, the inquest brings it all back again maybe two or three years later. That is not good enough; inquests should happen a lot sooner.

The key provisions of the Bill include clarifying that the purpose of the inquest goes beyond establishing the medical cause of the death and establishing the circumstances in which the death took place. In the case of farm accidents or road accidents, it is very final and very sad to know how the person died medically, but it is very important to determine what caused the accident so that we could eliminate that cause or prevent a case like it ever happening again. Another key provision is strengthening the coroner's powers to summon witnesses to an inquest and to direct a witness to produce documents and evidence and to answer questions. I think that is only fair because, again, families are waiting for the truth and that is very important. In some cases, witnesses may be after travelling from very far away. When the inquest takes place they have to travel a very long distance and maybe they do not have finances. Things like that have to be taken into account and it should be possible to try to help or finance someone who is having a difficulty coming to the inquest.

Another key provision is new powers for the coroner acting under a warrant from the District Court to enter and inspect premises and to take copies or possession of documents or material relevant to the inquest. That is very important because otherwise cases and the truth will not be made available. There will be appropriate penalties for witnesses not co-operating with the inquest and I believe that is very important also.

At this juncture, I would like to thank our own coroner in Kerry, Terence Casey, who retired last year after giving more than 20 years' service to south Kerry. He did a wonderful job in tough conditions. It is always tough when we go through the real aspects of what happened. We need good people to be able to withstand what they see. We are also very lucky, in respect of farm accidents and road accidents, that we have Inspector Jim O'Brien, who operates out of Tralee and is doing a tough job brilliantly. He has vast experience and is most helpful. We respect him for his expertise and his honesty and the great work that he is doing.

There is greater clarity and transparency in the mandatory reporting of certain types of death including a detailed list of specific examples of mandatory reportable deaths. I hope that suicide is not going to be one of these mandatory reportable deaths. Suicide is such a tragic death when it happens in a family and I do not think the general public needs to know what happened in those instances, that it was suicide. Families are going through enough and are trying to retain their dignity. I think it would be very unfair on these people if it had to come out publicly that their loved one's death was caused by suicide.

It will be an offence for a responsible person not to report a mandatory reportable death to the coroner. That is very important. There is to be updating and modernising of the provisions regarding post mortem examinations to take account of forensic developments and current practice. That is very important as well because as technology has improved we need to make provisions for it.

Reflecting on the provision of Deputy Clare Daly's Private Members' Bill regarding maternal deaths, I think that is most important and should have been there before but at least we hope it is to be in place going forward. When a couple loses a baby before it is born, in mid-birth or whatever, that should not be public knowledge to anyone beyond the family. It is very tough on a couple who may be trying to have a child and loses it before it comes into the world.

I am grateful for the opportunity to speak and I support the Bill.

Photo of Mattie McGrathMattie McGrath (Tipperary, Independent)
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Ar an gcéad dul síos, ba mhaith liom buíochas a ghabháil le Teachta Clare Daly. I thank Deputy Daly, although she said she did not want any thanks, and her team and the other people she mentioned as well. It is not only this piece of legislation; Deputy Daly has championed many a piece of legislation since coming in here. I worked on one or two of them. We can differ on many issues but she is tenacious and she will fight the battle to have these very sensitive and delicate issues sorted out. I want to support her on that.

The principal changes proposed in the Bill include new categories of deaths that must be reported to a coroner.

These include maternal deaths and the deaths of children during birth or in the year afterwards. It is such a sensitive, delicate and emotional time. One can never understand such a tragic loss unless one is involved. We cannot walk in those people's shoes so it is timely that we make necessary changes in a sensitive manner.

It concerns deaths of children during birth or in the year afterwards subject to limited exceptions. These exceptions are very important. The powers of the coroner to investigate not just the approximate cause of death but also the surrounding circumstances are very important. I salute coroners for the job they do, which is not an easy one. I also salute jurors who turn up. Normally the same people turn up. However, I have issues and campaigned in the last Dáil with some siblings whose loved ones died, mainly by suicide. In respect of the media having to be present, I know it is public and transparent but I appeal to the media not to report the minutiae where the circumstances are harrowing. I salute Trudy Lawlor, a renowned singer from County Laois who lost her brother to suicide, who has championed this cause and who has done so much work to make inquests user-friendly because they are not user-friendly. This Bill and others do not address it, which is a pity, but we might be able to introduce some amendments. First, the inquest should not be held in an adversarial courtroom, which courtrooms normally are. A courtroom is a cold place that intimidates people. Anyone going into a court, be they a juror or observer or, worse, on a charge, is intimidated. We tried very hard with the previous Minister for Justice and Equality, Alan Shatter, to move inquests to a different location such as a hotel or some other place with a soft ambience away from that adversarial environment with lawyers where other cases are taking place. It is not a suitable venue. We must be sensitive to the families who have been traumatised enough and as Deputy Danny Healy-Rae said, might have waited for the inquest for six, 12 or 18 months. It must be removed from that cold and archaic system. I am not saying we should lock the press out but the press has strict guidelines because there is no need at times to report some of the gory details of a sad and tragic accident or, worse, a self-inflicted death. It must be changed.

There will be increased powers for the coroner to procure post mortem examinations and to obtain documentary and other evidence. This is vital and long overdue. Sadly, there have been cases that have never been solved because of a lack of powers for the coroner. This must be done. There is provision for families of deceased persons to be informed of decisions relating to examinations and inquests and for civil legal aid to be provided. Of course, they must receive civil legal aid. It is a cold enough place. The coroners do their best but it concerns the whole system. The loss of a loved one is so traumatic and we need to have full disclosure. Getting the balance between deciding what are important facts to discover, what the family must go through and what the public needs to know is a sensitive and delicate matter. I know it must be transparent.

Farm accidents and road fatalities are very difficult for families. It is punitive if the inquest goes on for so long that insurance claims, payments or income are affected. The spouse and children might be left without any income waiting for this. We must always be conscious of that. Strengthening the powers is very welcome. Inquests must take place in the most sensitive venue and there are plenty such places. We know that with counselling and other issues. We have moved on a lot from the inception of the State and must ensure these sensitive issues are dealt with sensitively. It is not a matter of skipping any laws but making it more user-friendly for those unfortunate people or families who must live with the loss and grief and also try to get the result of the inquest. I wish the Bill well and hope there might be room for amendments to deal with the issues to which I referred.

7:55 pm

Photo of Eamon RyanEamon Ryan (Dublin Bay South, Green Party)
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I join the other Deputies in congratulating Deputy Clare Daly, her team and the people who have been campaigning on the reporting of maternal deaths. I commend the Deputy on that work. I will not go into the details of it because it is not an area in which I have expertise but I hope they will not mind if I use the opportunity to raise an issue and, hopefully, raise amendments that we will present to the Minister and Department on another related area concerning the Coroner's Court in which I do have an interest and some experience that might improve the coroner's process. This concerns fatalities from cycling accidents. It could apply to other traffic accidents but I have a particular interest in that area. I know we mentioned a great academic - a giant from Trinity College mentioned by Deputy Clare Daly. My comments are very much based on the analysis of Dr. Mike McKillen from Trinity College who, on behalf of the Dublin Cycling Campaign, has been trying to attend as many coroner's hearings as possible relating to road fatalities in Dublin involving cyclists in recent years to use that avenue or mechanism to ensure that we learn the lessons of each tragedy that occurs and that we try to understand what is happening, why so many cyclist fatalities are happening and what we can do to avoid them. In talking to Dr. McKillen, the amendments we will present will come directly from that experience in the Coroner's Court. They are coming from a very positive and constructive attitude and approach. The timing of this Bill is very useful for us. I am thinking very much of Luby Maryori Ramirez. I could name a host of other people who, unfortunately, have been involved in tragic deaths on the roads but I will mention her. She died in March 2017 on the roundabout from Whitehall Road and Templeville Road. Typically, so many of these incidents and cycling deaths involve an accident where a truck turns left and the cyclist is caught under the wheels. We all know of other cases. Several friends have died in such circumstances. The inquest into Ms Ramirez's death happened two or three weeks ago. It was attended by Dr. McKillen. Arising out of that, our suggestions are very practical and specific and I hope this Bill might be a useful opportunity to provide that insight into the running of the Coroner's Court.

These suggestions are very practical but that is what we need. In many instances in such hearings, evidence is presented to the jury often in respect of the vehicles involved, the mechanical evidence around the nature of the vehicle, the technology or the state of the vehicle. Based on our experience - I am talking about Dr. McKillen - that evidence is not presented in a public way. It is not on the record and we believe it should be. We believe that sort of evidence should be presented not just as evidence for the coroner and jury to consider but be made available publicly, which is not the case in our experience, so that the knowledge is shared and the full evidence is presented in a very public way.

These suggestions are very technical and specific and I will return to them on Committee and Report Stages if they are ruled in order. In respect of the evidence that is often presented in the Coroner's Court regarding traffic accidents, young gardaí might report on the evidence but it is often uncertain as to what their real expertise and their training is regarding the understanding, reporting and analysis of road traffic accidents. There is a real science around the recording, reporting and understanding of what is happening on our roads and what happens when fatal accidents or indeed any accidents occur. Dr. McKillen's experience in attending all these hearings is that it is often very uncertain as to what experience or expertise a Garda has and a lack of understanding of the training and development of the skills of the Garda.

I am not blaming the gardaí. They are put in an unfortunate situation if they end up attending a coroners court where they do not have skills and expertise. One of the recommendations we have in that regard is that the relative experience, expertise and training of the gardaí in such circumstances should be shared and made clear to improve the quality of the forensic analysis, reporting and understanding of what is happening in such fatal cases.

I listened with interest to the Minister of State refer in her speech to section 20 and the possibility of removing juries from dealing with some traffic fatalities where it is clear what happened, for example, a single vehicle accident. I am slightly nervous about weakening the provisions of any analysis of road fatalities, although I fully accept the difficulties that may arise where a jury cannot be empanelled and there is a series of adjournments, which is the last thing we want the family to go through. I accept, therefore, the need to be flexible. We need to raise the importance and significance of, and the attention given to, the coroners court process because 160 fatalities is an intolerable number. We should use the process to bring in people with expertise to understand how we could avoid these accidents.

In addition, we believe there is a case to be made - and we will try to draft an amendment on this - that in coroners court cases involving traffic accidents, particularly cycling accidents, although every fatality is a tragedy, there should be a provision that, for example, the National Transport Authority or another suitable authority such as a local authority should have a road engineer with expertise on hand to give evidence to the coroners court regarding what might be possible. I will give an example to demonstrate why we call for that. Following a tragedy on a roundabout, one might hear it said at the coroners court, "Nothing could be done. You can't put a cycle lane through a roundabout", when the cycling fraternity campaign knows that it is possible. It requires a different design perspective in terms of how our roads are designed, and that needs to be brought into coroners' reports. In that way, the highest level expertise is available to the coroners so, if there has been an accident at a particular junction, a complete reconfiguration of the road is possible. One needs the best experts in the court to present that evidence, so the coroner's findings and direction to the local authority has real effect. In our experience, that is not happening under the current system, as noted in the report of Dr. McKillen to the cycling fraternity. We are looking for a technical provision where the highest level of advanced road design engineering capability the State has is directed in such a way as to ensure it appears in any such hearings.

These are technical but important provisions. A final point is that the scheduling and information relating to coroners' hearings are often not easily available. Dr. McKillen might only hear of a coroners court hearing if the family directly communicates to say, for example, it is coming up next week. We would like greater public notice and provision for NGO organisations such as the Dublin Cycling Campaign or others interested in road safety, including the Road Safety Authority, to attend and contribute, and to have clear notice regarding such hearings. They are of huge public importance, particularly to those who are involved in trying to reduce the level of road fatalities.

I hope that is not inappropriate. The Bill relates to the issue of technical and other important amendments to the coroners process. It is correct to add some of the experience we have on how we might reduce road fatalities and improve the process of coroners reports in that regard. I welcome the opportunity to contribute on that basis.

8:05 pm

Photo of James BrowneJames Browne (Wexford, Fianna Fail)
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I wish to share time with Deputy Eamon Scanlon. I welcome the opportunity to contribute to the debate on the Bill, which aims to strengthen and modernise parts of the Coroners Act. I welcome that the Bill allows for wider scope of inquiry and seeks to address public unease regarding high profile cases, including maternal deaths. In the past, deaths relating to maternity care that should have been reported because there were issues of medical error, and were unnatural deaths, were not reported. Bereaved families experienced difficulty obtaining basic information with which they should have been provided. The increased powers afforded to the coroners in the legislation are welcome in this regard. In particular, I support the requirement that maternal deaths will now be the subject of an inquest. The introduction of mandatory reporting, post mortem examination and inquests into maternal deaths will now, hopefully, deliver the transparency, accountability and oversight that is long overdue. Hopefully, no more families who have had loved ones lost to them will have to struggle and fight to get the answers they are entitled to.

I commend Deputy Clare Daly and her team for pursuing this Bill, and the families who have had to suffer in the absence of these rights and powers. The Bill will also allow a coroner to inquire into a stillbirth where there is a cause for concern, for example, if this is raised by bereaved parents. In effect, all stillbirths, perinatal deaths and maternal deaths should now have to be reported to the coroner. I believe this is the way it should be and it is not before time. I hope the Bill will pass through the Oireachtas in a timely fashion.

Photo of Eamon ScanlonEamon Scanlon (Sligo-Leitrim, Fianna Fail)
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I am glad to have the opportunity to contribute to the debate. I knew Michael Kivlehan and his wife, and Sean and Sally Rowlette. I remember being in the hospital that night with Sean Rowlette as his young wife, a healthy woman, was in a hospital bed on a life support machine, with him having to make the decision as to when they would turn off the machine. Honestly, it is unbelievable to think that happened. It does happen, unfortunately, and it will happen again.

Afterwards, what I could not believe was the difficulty the Kivlehan and Rowlette families had and the trauma they went through to try to ensure inquests were held. It took a long time to ensure they were held. Those families had to go through a lot of unnecessary hardship to get what should be a natural right. After that, Sean Rowlette mentioned to me that Deputy Clare Daly had put forward a coroners Bill and I want to acknowledge that the Deputy pushed this Bill. Sean Rowlette asked me to support the Bill and that is the reason I am here tonight. I will support the Bill in any way I can and I am delighted the Fianna Fáil party is supporting the Bill.

Like previous speakers, I hope the Bill will pass through the Dáil quickly and that it will be dealt with long before Christmas. I would not like to see any family go through what I have witnessed two families go through, which was wrong and unfair. The only right way forward is to make sure this Bill passes as quickly as possible.

Photo of Mary Mitchell O'ConnorMary Mitchell O'Connor (Dún Laoghaire, Fine Gael)
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I will try to answer some of the questions. My officials have taken note of other questions and we will come back to the Deputies at a later stage.

In response to Deputy Fiona O'Loughlin, the reason we have proceeded with the reform of the coroners law in advance of reorganising the entire coroners system is to ensure the urgent changes needed on reporting deaths, including maternal deaths, and changes to the legislation on coroners' powers can be made quickly. As I indicated earlier, the Minister is also considering optimal organisation of the coroner's service.

While this may take further time, we all agree that the urgent measures contained in the Bill are needed now.

Deputy Clare Daly referred to the delay in bringing the Bill forward. The Minister for Justice and Equality has acknowledged that it has taken much longer than he wished to finalise the legislation for publication. I acknowledge that the Deputy thanked the Minister, his predecessor, Deputy Frances Fitzgerald, and my officials, Mr. Brendan McNamara, Ms Madeleine Reid and Ms Róisín Hennessy, who accompany me in the Chamber. Deputies Clare Daly and Fiona O'Loughlin also referred to the need for the legislation to bring about a change in communication and culture. I agree with them that ignoring people and dismissing their concerns must change. We must deal with patients and their families with empathy and respect. Deputy O'Loughlin raised the Scally report. I add my abhorrence at the treatment by some doctors, as outlined in the Scally report, of women in a disgusting, misogynist manner. We need basic humanity in all areas in our hospitals to deal with patients and their families.

Deputy Louise O'Reilly referred to missing persons. I have noted the Deputy's views on the Private Member's Bill proposed in this regard and I will bring them to the attention of the Minister. However, I understand the proposer of that Bill has agreed, following advice, that a reference to the role of coroner is not required to achieve the Bill's objectives. The Deputy referred also to iatrogenic suicide. The Minister says that the introduction of a verdict of iatrogenic suicide at an inquest was proposed on Second Stage of a Sinn Féin Private Member's Bill in the Seanad on 18 October 2017. The Government opposed the proposal and the Seanad voted not to approve the Bill. The Government cannot accept a proposal now to introduce a verdict of iatrogenic suicide. The position remains that the proposal, while well-intentioned, risks an inquest apportioning liability to a medical practitioner who may have prescribed the treatment or medication for the deceased person. A coroner's inquest cannot consider questions of civil or criminal liability. Section 30 of the Coroners Act 1962 provides against such considerations specifically. The Office of the Attorney General has advised that the Private Member's Bill was legally unsound in that a new verdict would be capable of ascribing criminal liability to a person or persons who would be readily identifiable.

I note in response to Deputy Danny Healy-Rae's concerns that we all agree that it is desirable to reduce the delays in the holding of inquests, which can occur despite the best efforts of coroners. The strengthening of coroners' powers and other reforms contained in the Bill should help to reduce unnecessary delays. I have taken note of Deputy Mattie McGrath's proposal that the Coroner's Court convene at a less adversarial and more sensitive site. We listened with interest to Deputy Eamon Ryan's comments on cycling fatalities. One change proposed in the Bill is relevant, namely section 14, which introduces the possibility for an inquest to make general recommendations arising from a death in the interests of public health and safety. That is all of the answers I have now but my officials can revert to anyone who wants further questions answered.

Question put and agreed to.