Coroners (Amendment) Bill 2018: Second Stage

Question proposed: "That the Bill be now read a Second Time."

I welcome the Minister to the House and call on him to speak on the Bill.

I am pleased to have the opportunity to speak on Second Stage of the Coroners (Amendment) Bill 2018, as now passed by Dáil Éireann. The Bill makes a series of amendments to the Coroners Act 1962 in a far-reaching and important modernisation of our coronial law. First, it will strengthen and clarify the powers available to coroners in the reporting, investigation and inquest of deaths. Second, the Bill responds to the Private Members' Bill brought by Deputy Clare Daly regarding maternal deaths. It also addresses similar concerns that have arisen in some perinatal or infant deaths. Third, the Bill provides 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.

I wish to acknowledge the important contribution of Deputy Clare Daly through her earlier Private Members' Bill on maternal deaths and thank her for the leadership she has shown on this issue.

That Bill addressed the findings of inquests and inquiries in several high-profile cases that caused great public unease. Some maternal 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 so reported. 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, unacceptable. I am introducing these provisions to significantly strengthen the powers of coroners so that will not recur.

Deputy Clare Daly's Bill received broad support from all sides in the Dáil. The Government agreed that I and my officials would work with Deputy Daly to progress the legislative proposals. The Bill I am introducing today, therefore, incorporates all the amendments sought by Deputy Clare Daly in respect of maternal deaths. The 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 will also extend the applicability of the legal aid scheme for family members at certain inquests to cases of maternal or late maternal death.

As well as addressing the issue of maternal deaths, my Bill provides for mandatory reporting to a coroner of all stillbirths, intrapartum deaths and infant deaths. As I mentioned, this responds to similar public concerns that have arisen in several cases involving perinatal and infant hospital deaths. I wish to emphasise that we are not proposing mandatory post-mortem examination or inquest in these particularly sensitive cases. Post mortem and inquest in such cases will remain, as currently, at the discretion of the coroner.

The wishes of the bereaved parents are a key consideration for coroners in such cases.

The Bill also introduces, for the first time, 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. These provisions fit logically into the overall purposes of the Bill, which sets out in a more comprehensive, clear, specific and stringent manner the legal framework for reporting and investigation of certain deaths. The Bill specifies much more clearly and comprehensively the situations in which a death must be reported to the coroner. These include any death that 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. The Bill also inserts a new schedule setting out specific types of death that must be reported to the coroner, including, for example, all maternal or late maternal deaths and all infant deaths.

Moreover, the legislation specifies more clearly and comprehensively the range of persons who are legally responsible for reporting a mandatory reportable death to the coroner and provides for updated penalties where this is not done. I should emphasise that in the majority of cases mandatory reporting does not result in a post-mortem examination and even fewer result in an inquest. Most reported deaths are quickly cleared from further investigation by the coroner, as the circumstances of death are well known and a death certificate can be signed and issued. However, 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. In a limited range of situations, which I will outline shortly, the Bill does provide for mandatory post-mortem examination, mandatory inquest or both.

The Bill sets out in a clearer, more comprehensive and more stringent manner a limited range of situations in which 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, specifically, any death occurring in State custody or detention, and any maternal death or late maternal death, as well as certain deaths where a post-mortem examination is already a statutory requirement. The coroner also retains a discretion to direct a post-mortem examination in other cases.

The Bill amends the 1962 Act to expressly set out the situations in which an inquest is required by law. These include 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. The Bill also specifies that 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.

The Bill introduces other important reforms. It strengthens the coroner’s powers to summon witnesses to an inquest, direct production of appropriate material, or enter premises and take possession of relevant documents. The Bill updates sanctions for a person obstructing an inquest, provides a modernised framework for post-mortem examinations, taking account of forensic developments, and requires family members to be informed regarding post-mortem examinations or inquests. In the light of the previous difficulties that have arisen, the Bill provides an important new power for the coroner to direct a hospital or other health institution, or a medical practitioner, to make available forthwith relevant medical records of a deceased person for the purposes of a post-mortem examination.

I should also mention a series of amendments relating to any case where the death that is the subject of the coroner's inquiry is also being investigated by the Garda Síochána Ombudsman Commission, GSOC, under the Garda Síochána Act 2005. Typically, a GSOC investigation will arise if a person dies in a vehicle collision following pursuit by a Garda vehicle, or after discharge of a Garda firearm or while in Garda custody. In such cases, the amendments recognise GSOC, rather than the Garda Síochána, as the lead criminal investigating agency. They also provide that the assistance to the coroner normally provided by the Garda Síochána in matters such as taking witness statements and producing forensic exhibits at the inquest will instead be provided by GSOC designated officers. This reflects the existing practice. It is clearly preferable for all stakeholders concerned in the interests of ensuring a visibly independent and transparent coroner’s inquiry.

The Government has agreed to priority drafting of a number of further amendments. These are being finalised and I intend to bring them forward on Committee or Report Stage. They include provisions for a coroner to seek directions from the High Court on a point of law relating to his or her functions - a consultative case stated provision. Another proposed amendment is subject to the Attorney General's advice, setting overall rules, and empowering me to make detailed regulations to guide the best conduct of a post-mortem examination for coronial purposes, and the proper and respectful storage and ultimate disposal of human tissue or organs removed for the purposes of the post mortem and retained for the inquest. Such disposal arrangements could include return to a family member for burial or cremation, if requested and appropriate. The detailed regulations will be developed together with the Minister for Health and appropriate stakeholders.

Many of the Bill’s provisions build on an extensive review by my Department of the Coroners Bill 2007, which also proposed to modernise and strengthen coroners’ powers but had become, in some respects, outdated. Of course, 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. However, we must continue to examine the optimum organisation of the coroner service.

Further elements of the existing law and structures will require significant improvement. Such improvement might likely involve a move away from the current multi-jurisdictional county model to a more regional one. However, no decisions have been taken. In the meantime, the Bill makes provision for a small number of immediate and necessary administrative amendments to assist coroners in carrying out their functions. This primarily concerns the Dublin district.

I will now address the main provisions of the Bill. Section 1 is a standard provision.

Section 2 provides for a number of new definitions in the 1962 Act, including "family member", "post-mortem examination", "stillborn child", and a range of situations that are defined as "State custody or detention". It also defines "maternal death", and a number of related terms, in accordance with the internationally recognised World Health Organization, WHO, definitions.

Section 3 provides an express statutory power for a coroner to inquire into a stillbirth where there is cause for concern. This addresses the question whether references in the legislation to a "deceased person" can apply to a stillborn child who has never drawn breath independently.

Sections 4 to 6, inclusive, contain a number of updating technical amendments regarding administration of the Dublin coroner district. These are necessary following the transfer, in late 2017, of responsibility for the operation of the Dublin coroner district from the Dublin local authorities to the Minister for Justice and Equality.

Section 7 inserts into the principal Act a new part IIA on reporting of death. It consists of two proposed new sections, the first of which is section 16A, which sets out comprehensively the general types of deaths which must be reported to coroners. It should be read in combination with the new Second Schedule contained in section 34, 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, intrapartum death or infant death. There is a power for the Minister to amend the list of reportable deaths by statutory instrument.

Secondly, 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 proposed section also updates the penalties for failing to report a reportable death.

Section 8 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 in all cases of maternal death or late maternal death.

Section 9 amends section 18 of the principal Act to provide that the coroner has a 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 10 is a significant provision that 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 - for strengthening our compliance with the European Convention on Human Rights, ECHR. However, it will remain the position that an inquest does not make any finding of civil or criminal liability.

Section 11 requires the coroner to give at least 14 days’ notice regarding the holding of the inquest to family members and interested persons. Shorter notice is permitted in limited situations as an exception if the family will not be unfairly prejudiced, for example, where the deceased is a foreign national and the coroner is facilitating repatriation of the body.

Sections 12 and 13 are further technical amendments arising from the recent administrative changes regarding the Dublin coroner district. Along with sections 14, 19, 20, 21, 23, 24 and 26, section 12 also makes provision for a designated officer of GSOC to assist the coroner in place of a garda, or recognises GSOC as the lead investigating agency in place of An Garda Síochána, in a case where the death is also being investigated by GSOC, as I mentioned earlier.

Section 14 modernises the current provision for identifying the body of the deceased person.

Section 15 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 10, widening the scope of the inquest.

Section 16 amends section 31 of the principal Act to include reference to the findings made at inquest in that section's prohibition of censure or exoneration and to add that general recommendations that are considered necessary in the interests of public health and safety may be appended to the verdict.

Section 17 amends section 32 of the principal Act to add a reference to the findings made at inquest in the record of the inquest’s conclusions.

Section 18 is a key section which provides for extensive reform of the Act’s provisions on post-mortem examinations directed by the coroner. It replaces sections 19 and 52 of the principal Act and amends section 33, which refers to the coroner’s discretion to direct that a post-mortem examination be performed. The section also proposes five new sections in the principal Act: sections 33A to 33E. Collectively, these provide for: a more detailed statutory framework where there is a mandatory post-mortem examination; a modern and more coherent process for the post-mortem examination to be performed by a pathologist under the direction of the coroner; requirements for a family member of the deceased person to be informed regarding the post-mortem examination and provided with a copy of the post-mortem report if requested; and a new statutory provision for the coroner to direct a further post-mortem examination of the body of the deceased if the coroner thinks it necessary.

Section 19 makes provision for a designated officer of GSOC to assist the coroner, in place of a garda, in a relevant death by serving witness or jury summons for the inquest.

Section 20 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. The court can make such other orders as it considers just, including an order as to costs.

Section 21 amends section 38 of the principal Act to significantly strengthen coroners’ powers regarding a witness at inquest. 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 and ancillary orders to give full effect to the direction. The offence of knowingly giving false or misleading evidence to an inquest is updated to carry a class A fine or imprisonment for a term not exceeding 12 months.

Section 22 provides for the coroner to take evidence before the inquest from a person who is about to leave the State, where that appears necessary.

Section 23 amends section 40 of the principal Act to remove the requirement that the coroner must sit with a jury in every road traffic death. This change has long been sought by coroners. Currently the jury requirement applies even 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 leading to unexpected adjournments and delays in many cases, distress to the bereaved families, and inconvenience to witnesses. The coroner would instead keep a discretion to empanel a jury in road traffic cases for which it is considered appropriate.

Section 24 is another section empowering a GSOC officer to assist the coroner in relevant cases, in this case in empanelling a jury for the inquest. Section 25 updates the sanctions under section 46 of the principal Act for obstructing the removal of a body to a mortuary or morgue. Section 26 is a further GSOC amendment and allows for a GSOC-designated officer to apply for exhumation of a body under section 47 of the principal Act in the same manner as a Garda inspector might. Section 27 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 take possession of any documents or material relevant to the inquest. Section 28 is a new provision that the coroner may obtain advice and assistance from an expert, if he or she considers it necessary, on a particularly specialised subject relating to the death.

Sections 29 and 30 provide for further necessary updates regarding administrative matters following the transfer of responsibility for the Dublin coroner office. Section 31 extends the scheme of legal aid in the principal Act for a family member of the deceased at inquest, which was introduced in 2013 for certain categories of deaths, to cases of maternal death or late maternal death. Section 32 inserts a new provision such that, 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 33 is a further GSOC amendment. It inserts a new express provision in the Garda Síochána Act 2005 for GSOC-designated officers to assist the coroner in relevant cases. Section 34 provides for the new Second Schedule that sets out for the first time in statutory form a specific list of concrete examples of deaths that must be reported to a coroner.

Sections 35 and 36 are standard provisions.

It is my strong view that this important Bill responds to the demands of bereaved families, of interested parties, and of society in general. It will provide the coroner with a modernised and coherent legal framework and with significant new powers to ensure an effective death investigation. I hope that, with the co-operation of all sides, we can facilitate its swift passage through this House with a view to enactment before the summer recess. To this end, I ask Senators for their co-operation on this issue. I commend the Bill to the House.

Gabhaim buíochas leis an Aire agus cuirim fáilte go dtí an Seanad roimhe. Molann Fianna Fáil an Bille seo. Fianna Fáil supports the Bill, which strengthens and modernises the current law governing coroners' inquests. In particular, Fianna Fáil supports the requirement that maternal deaths be the subject of an inquest. The Bill will also allow a coroner to inquire into a stillbirth where there is cause for concern raised by, for instance, the bereaved parents. Between 2011 and 2013, a total of 27 maternal deaths were recorded, of which only three were subject to an inquest. Families have spent years fighting for inquests into the deaths of their loved ones. The fact that it has proven 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 being learned that could prevent the recurrence of errors. There have also been inconsistencies in the way in which maternal deaths have been recorded in official statistics, which has led to significant under-reporting of these incidents.

That is not true.

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 other than those which occur in hospitals to establish the cause of death and any liability on the part of healthcare professionals. It is clear that this legislation is required to ensure Ireland is compliant with the European Convention on Human Rights.

More broadly, bereaved families and coroners have experienced considerable difficulty in obtaining basic information that should have been provided to them. The increased powers afforded to coroners by this Bill are welcomed. We support this Bill.

I again welcome the Minister to the House. I am glad that he is present for debate on this Bill because it is exceptionally important. In his opening address, he made reference to our colleague, Deputy Clare Daly. It is only right and proper that she be recognised for her significant contribution to making this Bill happen.

I have been on the Joint Committee on Justice and Equality with Deputy Clare Daly for a number of years and this issue has come before us. People who have experienced maternal deaths and who have not had the opportunity of an inquest have given testimony before the committee. This legislation, once passed by these Houses and signed into law by President Higgins, will at least mean this will not happen again.

It updates and modernises the legal framework relating to coroners, which has not been done since 1962 - generations ago. Things were done in a different fashion then. There was not the type of transparency and accountability back then that society takes for granted today.

We have EU obligations, as has been pointed out. This legislation certainly brings us into line with our EU obligations. The detail in the legislation is welcome. Most, if not all, eventualities that may present themselves are covered by the legislation. It is welcome that the penalties for people who do not co-operate with inquests and coroners will be increased. Coroners will have the power to ensure that people turn up, answer questions and give evidence in coroners' courts.

It is also welcome that families will be required under the legislation to be informed when inquests are taking place. That feeds into people's involvement with the justice system and ensuring that victims are at the heart of the work we do because, unfortunately, for too long in this country, victims have not been at the heart of the justice system. In fairness to this Government and Minister, we are moving incrementally in the right direction when it comes to a victim-centred society and justice system. It is heartbreaking to hear the stories of people who have suffered maternal deaths where the reasons for the death were inexplicable. The families will live with that for the rest of their lives. The reasons why it happened are inexplicable and nobody is held accountable. As far as the families are concerned, justice has not been done and there has been no attempt to ensure that justice is done. This legislation will at least give these people some satisfaction that in the future, such situations will not arise.

I welcome the Bill. I always have great admiration for the Minister because the raft of legislation he must put through is quite remarkable. This legislation will directly impact on the lives of citizens in a positive way, particularly when people find themselves in very tragic and difficult situations. At least they will know that there is accountability and transparency and that the justice system is on their side. I commend this legislation and I am glad that, so far, there has been no opposition to it in this House. As I always suspect, this House does the right thing when the legislation is important and necessary.

Gabhaim buíochas leis an Aire agus cuirim fáilte ar ais roimhe i seachtain atá iontach gnóthach dó. I welcome the Minister back to the House during what is a very busy week. I know it will be another busy week next week for him in respect of justice legislation coming before this House.

However, I seek his forgiveness. I must return to the Special Select Seanad Committee on the Withdrawal of the United Kingdom from the European Union upon conclusion of my remarks but, as Senator Conway said, there is support for this legislation in this House and I look forward to engaging on it on later Stages. I also reiterate words of thanks to our colleague on the Joint Committee on Justice and Equality, Deputy Clare Daly, who will be a member for another few weeks. She brought this issue to the fore. While I do not say this in a confrontational or combative way, in many ways, her diligence has resulted in this legislation being brought forward by the Government. That is part and parcel of our work here and it is important that we acknowledge that.

We in Sinn Féin believe it is incredibly important that the remit of inquests be 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 consider these matters holistically if the case 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. The powers the Bill gives to 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 previously, such as in the cases of maternal deaths and others, coroners' powers have proven to be ineffective in investigations. The legislation seeks to give the coroner powers of warrant and search and seizure of documents and penalises those who refuse to co-operate with inquests. I am glad 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, by unfair means or misadventure or in other areas.

The legislation responds to Deputy Clare 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 stands, maternal deaths are treated as deaths that 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 this and ensure there are mandatory inquests, we must also address the failures that lead to the need for inquests. 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 led directly to heartbreaking incidents involving mothers and children, including, in some cases, their tragic deaths. 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 maternity strategy and other relevant measures. The national maternity strategy has no statutory underpinning and significant swathes of it have not been implemented. We must also address the issues while ensuring there are mandatory maternal death inquests.

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 coroners legislation for which Senator 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 this syndrome 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 introduced by Senator Mac Lochlainn some years ago proposed to amend the Coroners Act to make it 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 a number of Ministers for Justice and Equality, the Bill does not cater for the measures it wishes to see included. Sinn Féin will submit an amendment on Committee Stage to introduce the measure and we look forward to engaging and working with the Minister in that regard.

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 provision for a coroner to inquire into a stillbirth where there is cause for concern, for example, arising from matters raised by the bereaved parents should be put on a statutory footing. We also believe it is essential that this legislation should provide for the Minister to make regulations on the proper storage and family management of any material removed for the purposes of a post-mortem examination, including return to a family member 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 a number of areas in which we will seek to be constructive. We, along with the Minister and other colleagues, will seek to strengthen this legislation. We support the aims and objectives of the Bill and I thank everyone, including the Minister, who in one way or another has been raising issues concerning inquests into deaths in this State for many years. This legislation is a result of their tireless pursuit of justice on behalf of the bereaved families.

This legislation is very welcome and the changes are necessary. I have one issue, however, which I raised a number of years ago. It is about inquests being held in a timely manner and I am not sure, having examined the Bill, whether this issue is contained within it. We have been talking about maternal deaths and, when I raised this issue a number of years ago, it followed a maternal death into which, even after 18 months, an inquest was not held even though all the relevant examinations had been done. The maternal death was no fault of the hospital but the delay gave the impression that the hospital had something to hide. Despite numerous requests to the coroner, there was a substantial delay. Have we provided for this? It is a very important issue.

A section in the Bill gives power to certain people to look for an inquest but this power is not given to members of the medical profession who may require an inquest. A form can be filed under section 33A(2), which states that it shall be the duty of a coroner to exercise his or her power to direct a post-mortem examination in every case in which a member of the Garda Síochána, a member of the Defence Forces, a duly authorised officer of a statutory body or a designated officer of GSOC requests him or her to do so but it is not required where a medical practitioner so requests him or her. Section 33A(3) does provide for this requirement but I ask the Minister for clarification on the matter. Would it be appropriate to look at whether a post-mortem could be required to be held where a medical practitioner requests one? I was recently asked for advice in a case where there was clear evidence that a person who gave birth to a stillborn child had been seriously assaulted. The Garda got involved and I welcome the provision in the Bill for an inquest to be required in such cases.

I also believe the provisions will require additional supports for coroners because there is a lot of work in this area. Perhaps some of the delays in holding inquests are as a result of insufficient support mechanisms. Now that we are expanding their role and giving them more powers, it is important to make sure coroners have adequate supports so that they can hold inquests in a timely manner. It is also important that all the other necessary investigations, by the Garda and by medical professionals etc., are dealt with in a timely manner. I had another case in which an inquest was delayed for more than 18 months because of an ongoing GSOC inquiry. It was only by making representations for the inquiry to be concluded that the inquest could be held. A young person had died and the parents were left in limbo for more than 18 months. We need to make sure that inquests are not delayed ad infinitum, especially where a family has suffered a bereavement and wants an explanation, which they can only get through an inquest. Until all the evidence is made available, there are only uncertainties. I ask the Minister to deal with this as it is an important issue in regard to this legislation.

I welcome the opportunity to speak on this important and long-overdue Bill, for which I offer my support and that of my Labour Party colleagues. I also acknowledge the people in the Gallery to hear the debate. As the Minister said, the Bill serves a number of purposes. It will provide a long overdue modernisation of our current coroners system and will update and modernise the legal framework for coroners, in addition to ensuring that a wider scope of inquiry will be available to coroners and enhancing our compliance with the European Convention on Human Rights.

I acknowledge the important work that coroners do. Coroners themselves have been looking for this legislation and, while they have carried out their functions to the best of their ability, it has been in the context of a very dated legal framework. They have shown sensitivity over many years in the way they have dealt with bereaved families. Coroners systems are about addressing the concerns of bereaved families and that makes this a particularly important and sensitive Bill. I note Vicky Conway's very good and comprehensive piece on this Bill in The Irish Times of 17 May in which she made it clear that inquests must prioritise the needs of bereaved families, something the Department's working group noted in 2000 when calling for fundamental reform of the law on coroners.

I also acknowledge the great work of Deputy Clare Daly on her Private Members' Bill, whose provisions this Bill incorporates, specifically regarding maternal deaths. I pay tribute to Deputy Daly who, for many years, highlighted this by tabling parliamentary questions and working with interest groups and bereaved families to ensure that it would be something for which this legislation would provide. I acknowledge the work of Dr. Jo Murphy-Lawless from Trinity College Dublin, whom I have known for many years and to whom I am grateful for contacting me personally about this legislation, which her work also fed into. She co-ordinates the Elephant Collective, a group that was set up in response to concerns about maternal deaths. The group has done an exhibition called Picking up the threads: Remaking the fabric of care. Dr. Murphy-Lawless is a real testimony to Trinity College Dublin and I wish her the very best on her retirement.

I also acknowledge the families who have been so affected by maternal death and who worked so hard with Deputy Clare Daly to bring the legislation to this stage, in particular the families of Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette, all of whom died in maternity care between 2007 and 2014 and whose families have worked to ensure better legal frameworks of support for families in such circumstances.

I acknowledge the work of the Association for the Improvement of Maternity Services, AIMS, which has worked hard on this issue for many years. This legislation is hugely important, especially for the families of women who have died within maternity or maternity care services. The legislation will also provide for the mandatory reporting of all stillbirths, intra-partum deaths and infant deaths in that context to a coroner. This is not just about the deaths of women but also the deaths of children. That is a hugely significant factor and it is very important that we legislate for it. Unfortunately, we know of a significant number of maternal deaths, on which there should be a focus, as well as on the importance of the legislation in enhancing public trust and confidence and the confidence of women in maternity care services in Ireland. That confidence is not helped by responses such as that of the National Maternity Hospital, which suggested in 2018 that a Health Information and Quality Authority, HIQA, review following the untimely death of Malak Thawley was unjustified and might undermine clinical and public confidence and that its effect on national maternity services could be counterproductive. That was an unfortunate response because, as one of the co-chairpersons of AIMS, Ms Krysia Lynch, has noted:

Women deserve to know they will receive the best possible care with skilled, highly trained professionals looking after them, who can cope with any eventuality in the maternity continuum. They also need to be assured that when mistakes happen, they will be fully evaluated and compared to a national independent standard and that any learning can be transferred to other units.

This legislation and its provisions on maternal deaths should be seen in the context of a long history of the disregard and ill-treatment of and injustice for women and children within the healthcare system. We are finally moving out of that context. I again acknowledge the work of both this and the previous Government in seeking to improve conditions for women and children. However, it is worth remembering that in the past women in Ireland's maternity services were faced with scandals about which we only now know, including the symphysiotomy and hepatitis C scandals, the current revelations about cervical cancer screening and the bigger picture of the eighth amendment, which, happily, we have repealed.

This discussion and context came to the fore again this week when we learned of how Majella Moynihan had been treated by the Garda two decades ago, which we are also discussing in the context of our debate in this House on the Adoption (Information and Tracing) Bill 2016. We will have an opportunity to speak to the Minister for Children and Youth Affairs, Deputy Zappone, about that Bill later and I am working with her to ensure it will be improved on. We need to reflect on the history of the unjust treatment of women in healthcare services and this legislation will mark a major improvement in that regard. I acknowledge and reiterate what Deputy Clare Daly said in the Dáil when she noted the need to bring forward this Bill without delay. She also expressed some concern that the amendments the Minister proposed to bring forward on Committee and Report Stages in the Seanad would delay the Bill. Neither I nor my party will be putting forward amendments, as we wish to see this Bill brought into law as soon as possible. I am sure that view is shared across the House. If Government amendments are brought forward on Committee or Report Stages, we all hope they will not delay the passage of the Bill into law and that it can be dealt with before the summer recess, as Deputy Clare Daly had hoped. I know that the Minister also shares that hope.

I again refer to Vicky Conway's article in The Irish Times because inquests and a robust coroner service clearly play important roles in preventive healthcare. Inquests prevent future deaths because a key point of them is that by understanding what has caused a death within a system, they can make preventive recommendations. The World Health Organization reports that 80% of maternal deaths, that is, mothers who die within six weeks of childbirth, are preventable. Inquests can provide both the public and bereaved families with greatly enhanced information on how to prevent such deaths in the future.

I commend the Minister for introducing the Bill, as well as all of the campaigners who have helped to bring it to this stage. I look forward to its speedy passage into law.

I thank Senators Ardagh, Ó Donnghaile, Colm Burke and Bacik for their contributions and acknowledge their support for this important measure. I am grateful for the many expressions of support received and will certainly bear the various points raised by Senators in mind as I proceed, between now and Committee Stage, to address some further amendments and observations. I welcome the general agreement on the need to proceed swiftly to enactment of this important Bill as we modernise the Coroners Act 1962. I was particularly struck by the supportive words of Senator Bacik.

The reforms provided for in the Bill are needed to better serve citizens, clarify and strengthen the powers available to coroners and better support compliance with the State’s obligations under the European Convention on Human Rights. Like Senator Bacik and others, I acknowledge the work of coroners throughout the State, which is often or always performed at times of great sensitivity and challenge, as well as their often under-appreciated role in society. That is why I am keen for the Bill to ensure coronial law will better fulfil what is an essential and basic purpose in many respects - the provision of the best possible explanation for next of kin and, beyond them, society at large when a death gives rise to concern, doubt or uncertainty.

It is useful to recall the main reforms provided for in the Bill. It will strengthen significantly and modernise the powers available to coroners in reporting on, the investigation of and holding inquests into deaths and, in particular, provide for mandatory reporting to a coroner of a clearly specified range of deaths, including deaths in State custody or detention and all maternal or late maternal deaths, stillbirths and infant deaths. It will also provide for mandatory post-mortem examinations and inquests into all maternal or late maternal deaths and deaths in State custody or detention. It will clarify and expand the categories of persons who have a duty to report such deaths and it will be an offence for such a person not to do so. This will ensure proper and transparent scrutiny of deaths.

The Bill will update and modernise the provisions for post-mortem examinations to take account of forensic developments and current practice. It will strengthen the powers of the coroner to summon witnesses to an inquest and to direct a witness to produce documents and evidence or answer questions. It will give the coroner a new power, enforceable on application to the High Court, to direct a hospital, other health institution or medical practitioner to produce the appropriate medical records of the deceased for a post-mortem examination. The coroner will also be granted the power, acting under a warrant from the District Court, to enter and inspect premises, take copies or possession of any document or material that might be relevant to the inquest and provide for a wider statutory inquiry, where necessary, at the inquest. The purpose of an inquest will now go beyond establishing the medical cause of death. It will also establish the circumstances in which a death took place. The Bill will require information on the post mortem and, on request, a copy of the post-mortem report to be provided for the family of the deceased. It will require advance notice of an inquest to be given to the family members of the deceased person. That was one of the issues raised by Senator Colm Burke. It will also extend the current legal aid scheme for the next of kin at an inquest to cases of maternal or late maternal deaths.

A number of points and queries were raised. I again thank Senators for their contributions.

Senator Colm Burke raised a query about a medical practitioner requesting an inquest. This engagement on the part of a medical practitioner will take place earlier in the process. A doctor who may, for example, have been involved in treating a person prior to death will make immediate contact with the coroner after death. The doctor will state whether he or she can certify the death as being natural. This process, expressly provided for in the Bill, arises where, for example, a doctor is unable or unwilling to certify the death. This, of course, will give rise to a situation where further inquiry will be made by the coroner. In the event of the doctor having any concern, the coroner will normally direct a post mortem. If the post mortem does not, at that stage, resolve any concerns or uncertainties arising, then an inquest will be directed by the coroner.

The Senator also raised the important issue of delays. He is correct that there are often circumstances in which families or interested parties find it difficult to accept a lengthy lapse of time. Oftentimes, that gives rise to a greater level of upset, stress and trauma. Every effort is made by coroners to ensure that such inquests are held within a reasonable timeframe. However, among the amendments I intend to bring forward on Report Stage is one that will make further provision regarding adjournment of inquests, including where there may well be criminal proceedings. An amendment will address the need for the coroner and particularly the bereaved family to be kept fully informed of the progress of proceedings. If there is a reason or justification for an adjournment or time lapse, that will be made clear to the interested parties, particularly the family of the deceased. There will, of course, be a need to avoid any delay that could be regarded as undue or which gives rise to further difficulties. We will come back to that point on Committee Stage.

In conclusion, the Bill introduces a range of clear reforms to strengthen the powers of the coroner, to help reinforce investigations of deaths and inquests. It will ensure clarity for responsible persons, including hospital authorities, in ensuring that those deaths reportable to the coroner are reported in a timely manner. The changes will support the development of transparent and accountable oversight for investigating certain types of deaths and will support timely and coherent provision of information to bereaved families by the health and other authorities.

In my introduction, I acknowledged the contribution of Deputy Clare Daly over and above others. There were others who contributed in the Lower House. I also acknowledge what Senator Bacik has said about some of her colleagues and, indeed, the expertise of Senator Colm Burke. I am happy to repeat the acknowledgement of Deputy Clare Daly in particular.

This important Bill responds to the demands of the next of kin, concerns expressed in this House, in Dáil Éireann and in society in general, and I hope, with the co-operation of Senators, that we can facilitate passage of the Bill before the summer recess. I do not wish to take anybody short but I formally notify Senators that I have requested early dates for Committee and Report Stages, perhaps next week and the following one. As Senators will know from my engagement on the Judicial Appointments Commission Bill, I am entirely in the hands of the Senate on these issues. I am determined that the Bill is prioritised and would like it to proceed in early course.

Question put and agreed to.

When is it proposed to take Committee Stage?

Committee Stage ordered for Tuesday, 25 June 2019.
Sitting suspended at 2.46 p.m. and resumed at 3.15 p.m.