Marcella Corcoran Kennedy (Offaly, Fine Gael)
Link to this: Individually | In context | Oireachtas source

I am pleased to address the House today and to have the opportunity to discuss the outcome of the symphysiotomy ex gratia payment scheme and the report of Judge Maureen Harding Clark, assessor to the scheme.

We have all been touched by the stories of the women who underwent symphysiotomy, and the Government's aim was to take a person-centred and as dignified an approach as possible to help bring closure for as many of these women as possible. I believe the scheme has helped to bring that closure to a large number of women, and I welcome that.

Following examination of two earlier independent reports, which were commissioned by the Department of Health, it was agreed by Government in July 2014 to establish an ex gratiascheme for women who underwent a surgical symphysiotomy. The surgical symphysiotomy payment scheme was established in November 2014 following engagement by the then Minister for Health with the three patient advocacy groups that support women who underwent the procedure. It is important to note in our discussions here today that two of those advocacy groups strongly welcomed the Government approved scheme. One of those groups has said that their clients were happy to have been vindicated and had their suffering acknowledged. This support group also indicated that it had very positive feedback concerning the scheme from the women and their families, and it stressed the importance of providing redress for the women, given the older age group to which many of the women belong. This group has indicated that it supported in excess of 250 of the women in 2015. One of the groups rejected the scheme and continued to advocate for court settlements for the women. It indicated that it represented around 350 women.

The scheme provided an alternative, non-adversarial and person-centred option for women, many of whom were elderly and did not wish to pursue their cases through the courts.

In regard to research into symphysiotomy, the first independent report commissioned by the Deportment was undertaken by Professor Oonagh Walsh. Professor Walsh is a renowned medico-social historian with a special interest in female medical history. Professor Walsh outlined the history of symphysiotomy in Ireland and recommended that an ex gratia scheme be established. Importantly, Professor Walsh's research also included a national public consultation process with the women themselves and with other interested bodies. Professor Walsh undertook a number of public meetings, individual meetings and also received written submissions by post and by e-mail. It was an important aspect of the research to hear views from the women directly. The Walsh report noted that symphysiotomy was an exceptional and rare intervention in obstetric practice in Ireland. The procedure was used in mild to moderate disproportion and in obstructed labour. It occurred in less than 0.05% of deliveries between 1940 and 1985. The report estimated that approximately 1,500 symphysiotomy procedures were undertaken in Irish hospitals and that there were around 350 women still living who underwent the procedure.

The second report was prepared by Judge Yvonne Murphy who was commissioned by Government in 2013 to undertake a further independent review on the legal aspects of symphysiotomy in Ireland. Judge Murphy advised Government on the merits and costs of proceeding with an ex gratia scheme relative to taking no action and allowing the court process to proceed. Judge Murphy also placed advertisements in national and local newspapers seeking the views of women and what would bring closure for them. There was a very positive response to this advertisement. Judge Murphy met in person with all those who wished to meet, had telephone conversations with those who were too frail to travel and also received letters from other women with their views as to closure. Judge Murphy also recommended that an ex gratia payment scheme be established.

Judge Clark provided a comprehensive report on the surgical symphysiotomy payment scheme in October last year and we now have available a very thorough overview of the historical and medical context of symphysiotomy. The report also included a number of appendices, with documentary evidence from the annual clinical reports of the major maternity hospitals between 1940 and 1960 on the indications for use of this rare procedure. They also included extracts from the Transactions of the Royal Academy of Medicine between the 1940s and 1960s on this topic. Contrary to some reports in the media, the information in these appendices clearly shows that symphysiotomy was not a secret or illegal procedure but its use was reviewed and discussed by obstetricians at the time.

The total cost of the symphysiotomy payment scheme was just under €34 million, and payments of €50,000, €100,000 or €150,000 were made to 399 women who met the criteria for an award.All the women have received their respective payments, totalling €29.85 million. The majority of claimants were aged over 75 years. Payments were made to women between the ages of 51 and 96 years of age. The scheme was designed to be simple, straightforward and non-adversarial, and to offer the women an alternative to pursuing their case through the courts, if they wished. The women were not expected to give oral testimonies as they might do in a court setting. Although the scheme was non-adversarial, it took into account that women may have wished to consult a solicitor, and take legal advice and assistance in submitting their applications to the scheme.

In the interests of accountability, the scheme required each applicant to prove that she had a surgical symphysiotomy or a pubiotomy in order to be considered for an assessment of an award. The level of proof required to qualify for an award was clearly set out in the terms of the scheme. It is important to note that the proof required was considerably lower than the burden of proof required by the courts.

Judge Clark worked with each woman or her legal representative to locate medical records. She met some of the women in different parts of the country, where she considered this was necessary. Where claims could not be reconciled with established facts, women were examined by relevant medical experts. Judge Clark encouraged women who believed they had a symphysiotomy to apply to the scheme, advising them that they would not be giving up their right to pursue their case through the courts. It was only on accepting an award under the scheme that a woman had to discontinue her legal proceedings. The vast majority of women opted to do so.

The scheme was administered to the highest standard, in line with its terms of reference. At the end of the scheme, all applications and supporting documents were returned to the applicants or were confidentially shredded in line with each applicant’s wishes. The scheme did not hold any original medical records. In order to undertake her role under her terms of reference in an informed manner, Judge Clark drew on the professional expertise of certain medical specialists. These clinicians specialised in the areas of obstetrics, radiology, orthopaedic surgery and pelvic injury, urology and urogynaecology, and advised the scheme throughout the process. This ensured an effective, fair and well-informed method of assessment of the applicants by means of a comprehensive clinical case review in line with best practice whenever this was required.

Many hundreds of hours were spent examining the applicants’ medical records. Each application received an individual, careful assessment. Medical evidence was sought to explain delivery records. When claims could not be reconciled with established facts, the applicant was examined by relevant clinical experts. Some applicants were examined by several experts. When all efforts to obtain records failed, the scheme moved to seeking secondary proof of symphysiotomy, by evidence of a scar, and radiology evidence. Out of almost 600 applicants, 185 women were unable to establish that they had a surgical symphysiotomy. The report states that all these applicants were assisted by members of the team in trying to establish their claims, and the scheme’s resources were applied in rigorous investigations before a claim was declared ineligible for the scheme. Some 23 women experienced a spontaneous symphysiotomy during birth. While this condition is not particularly common, it is well-recognised. These women did not quality for an award under the terms of the scheme because they did not have a surgical symphysiotomy.

Pubiotomy is a distinctly different and outmoded procedure to symphysiotomy. It was also included in the scope of the scheme, at the request of the support groups. Pubiotomy was frequently claimed by applicants but was established in only one case. Significant disability was established in this case. In regard to international research, the authoritative Cochrane review is considered internationally as the gold standard of best practice in medicine. It gives an explanation of the procedure:

Symphysiotomy is an operation to enlarge the capacity of the mother's pelvis by partially cutting the fibres joining the pubic bones at the front of the pelvis. Usually, when the baby is too big to pass through the pelvis, a caesarean section is performed. If a caesarean section is not available, or the mother is too ill for or refuses caesarean section, or if there is insufficient time to perform caesarean section (for example when the baby's body has been born feet first, and the head is stuck) symphysiotomy may be performed.

Contrary to many reports in the media, symphysiotomy does not involve breaking the pelvis, or sawing through bone but, as described in the Cochrane review, the procedure involves cutting the fibrous cartilage of the pubic joint.