I move:
That leave be granted to introduce a Bill entitled an Act to amend, consolidate and extend the law relating to coroners, coroners' investigations and coroners' inquests, to provide for the establishment of a body to be known as an tSeirbhís Chróinéara or, in the English language, the Coroner Service, to define its functions, to provide for certain transitional matters including the completion of inquests commenced under the Coroners Act 1962, the transfer of certain documents preserved under the Coroners Act 1962 to the Coroner Service and the continuance in use of certain forms under that Act, to repeal certain enactments and provisions of enactments, to amend certain enactments and to provide for related matters.
This legislation originates from a parliamentary question I tabled to the Minister for Justice and Equality to seek an automatic inquest in the case of every maternal death in the State. This issue comes on the back of eight inquests into maternal deaths between 2007 and 2013 which returned verdicts of medical misadventure. The bereaved families did not receive these verdicts in internal inquiries and investigations carried out by the hospitals involved; they had to fight tooth and nail for the inquests to be carried out.
The response I received to the parliamentary question was that the issue was being considered as part of the consideration of the Coroners Bill, 2007. That would be grand, except that that Bill was initiated eight years ago. It is worth pointing out that it arose from recommendations made by the coroners review group in 2000 and the Coroners Rules Committee in 2003. The reviews recommended a comprehensive overhaul of the Coroner Service, including the legislation governing the work of coroners and the support services available to them. In 2013 the former Minister for Justice and Equality, Deputy Alan Shatter, told us that he hoped to be in a position to progress the Bill, but here we are in 2015 and not there yet.
The reason I am pushing this legislation is it is absolutely and urgently needed. It is largely the 2007 Bill with the addition of a provision to provide for an automatic inquest in cases of maternal deaths. It is urgently needed given the experiences of the families of the women who tragically died during childbirth in the past few years. Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette all died as a result of medical misadventure. A total of 14 children lost their mothers, yet the bereaved families had to fight to get that verdict.
Why is a verdict important? It is important not just to give the families closure but also to help prevent future deaths. It is an absolute necessity. The partner of Bimbo Onanuga had to fight for three years to have an inquest carried out which finally explained to him what had happened in her tragic death. There are examples of coroners declining to recommend the holding of an inquest in the case of a maternal death only to grant one at a later stage, with the inquest returning a verdict of medical misadventure. This issue is hugely important. In the case of Dhara Kivlehan who died in 2010 in a complicated cross-Border case, it took huge pressure on the part of her husband and legal wrangling with the HSE to have an inquest carried out into his wife's death. He was disrupted in his efforts at every stage, but the inquest helped. Tragically, the lack of an automatic inquest in that case possibly contributed to the failure by Sligo Regional Hospital and the HSE to learn vital lessons which might have prevented the death of Sally Rowlette from the same condition in the same hospital in 2013. It should be remembered that she left behind four children.
It is not good enough for the Government to decide it can leave legislation, which was initiated for seven or eight years ago, and take the view that it is not urgent. It is very urgent for pregnant women in hospitals in this State. It is up to the Government, the Ministers with responsibility for health and justice and the HSE to ensure that women who are giving birth in Irish hospitals receive the highest quality of care. Sometimes things go wrong. Tragically, that is part of life. However, when things do go wrong, it should be admitted, owned up to, acted upon and learned from to ensure other families do not go through the same tragic experiences. Providing for an automatic inquest in these cases is the one sure guarantee of that.
