• Gill Boden

Today Ireland’s new law on mandatory inquests for all maternal deaths will be ratified.


At last, the Elephant Collective reaches a long-sought goal this week. The Oireachtas (Irish legislature) schedule for Wednesday, 10th July, states that at 17.35 pm the Coroners (Amendment) Bill 2018 will be ratified by Dáil Eireann, the Irish parliament. The bill will then leave the Houses of the Oireachtas at once to be sent to Áras an Uachtaráin where President Higgins will sign it into law by the 17th July. It is seldom that a group of ordinary citizens have marked each moment in the protracted work of drawing up a complex new piece of legislation, let alone having been so centrally involved from the outset.

Amongst its core measures, the new Coroners Act 2019 will ensure:

-mandatory inquests for all maternal and late maternal deaths

-mandatory reporting of all maternal deaths, stillbirths, intrapartum deaths and infant deaths

-increased powers for coroners to command compliance from hospitals about the production of records and documentation to a maternal death in a timely manner, including applications to the High Court for an enforcement order should that become necessary

-legal aid for families involved in maternal death inquests

So far as we know, Ireland will be the first European country to have a specific clause written into the statute books on mandatory maternal death inquests (in other jurisdictions, maternal deaths might fall under general pre-existing statutes about inquests but are not specifically cited).

We, the Elephant Collective, are a group of birth educators, midwives, midwifery students and birth activists who first became involved in the issue of inquests for maternal death in relation to the death of Bimbo Onanuga in March 2010 (see Jo Murphy-Lawless, A brief glimpse into hell, AIMS Journal, Vol.26, No 1,

Having fought for an inquest into Bimbo’s death, the Collective took shape in the autumn of 2014 when a further three inquests, also hard fought-for by the families of Dhara Kivlehan, Nora Hyland and Sally Rowlette ended in verdicts of medical misadventure. We needed more substantive action. We already knew that the much- vaunted statement, ‘Ireland is the safest place in the world to give birth’ rolled out by successive Irish ministers of health simply did not hold water, not least because up to 2009 accurate data had not been collected nationally. We knew the depth of how families had suffered in the wake of a death.

Mandatory inquests were a vital next step. Clare Daly, then the Independent4Change TD (teachta dála- our Irish MPs), with her hard-working staff retrieved a 2007 bill to reform the coronial system, brought it up to date, inserted the precious clause about mandatory inquests for all maternal deaths and submitted it as a private member’s bill in 2015. Clare had already been active in helping us to gain the inquest for Bimbo Onanuga and attended her inquest.

The Elephant Collective determined to work at the public level to raise consciousness about maternal deaths, alongside the work of the bill, began to evolve its multi-media exhibition, Picking Up the Threads. Ultimately this exhibition, with its documentary, toured 14 separate venues around the country while we made use of national and local media and press to explain the critical importance of this legislation and gained the support of 24 county councils for the bill. In May 2017, the then Minister for Justice Frances Fitzgerald gave an undertaking that Clare’s private member’s bill would be adopted by the government. The current Minster for Justice Charles Flanagan, published the bill as a government measure in August 2018.

Step by intensively detailed step, we have all seen this through: Clare and her team, Eadaoin O’Sullivan, Liz Cassin, and Rhona McCord, the Elephant Collective, present for each stage of the legislative process, and the families directly affected. Critical interventions and shifts in emphasis have been hard debated and hearts won across the country. Civil servants in the Department of Justice worked extraordinarily hard to make this safe, sound draft legislation to be put in front of the Oireachtas. On the 15th May, the bill passed all stages in the Dáil. Deputy, now MEP, Clare Daly stated in the course of that debate:

We need and want a health system that works for women and their families; a health system that does not compound the families’ suffering by denying, defending and covering up in the face of the most devastating tragedy... We need transparency, we need inquests and we need recognition of the wrong. We also need les­sons to be learned. We have a responsibility to the women, to the families of the women and to the campaign­ers. I want to pay tribute to those campaigners, to the activists in the Elephant Collective, many of whom are in the Public Gallery today, to the 24 county councils in the State that passed mo­tions calling for mandatory inquests into maternal death, and to all those who sent letters to the Minister and who emailed and called to keep the pressure on to get the Bill to this point. I pay particular tribute to the families. Their struggle has been extraordinary. The families are ordi­nary people who have lived through extraordinary tragedy. The families’ dignity, persistence, dedication and strength is absolutely humbling. I am totally in awe of the families and so very glad that we are here today.

As the bill passed on to the Seanad, we were aware of the extent to which the public discourse on maternal deaths had changed utterly since Bimbo’s death in 2010, and her subsequent inquest in 2013. Here is what the Minister for Justice said on 19th June in the Seanad:

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. Thirdly, 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.’

At differing points in the Seanad debate, senators pointed to the fundamental connection between a rigorous public examination of maternal deaths and creating greater safety for all women:

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.’ Senator Ivana Bacik, 19th June, 2019

The Bill is a positive step. We are aware, however, that under the global gag rule, for example, we seen an increase in maternal deaths internationally. Along with steps backwards in technological and medical practices in many parts of the world, we have also seen the restriction of women's rights, medical supports and funding. Those factors have led to an increase in maternal deaths. I hope, therefore, that this Bill will not only be positive for families in Ireland. I hope it will allow Ireland to be a strong advocate in the area of maternal health and rights internationally, at a time when such advocacy is very much needed. I commend the former Deputy, Clare Daly, MEP, as well as the families and the Minister.’ Senator Alice Mary Higgins, 3 July 2019.

As a formal public undertaking, an inquest, without fear or favour, sets out in detail the train of circumstances leading to an unexpected death. This will now happen for all maternal deaths in compliance with Article 2 of the European Convention on Human Rights which sets out the following rights:

-Right to life

-Right to know why sudden death has occurred

-Remedy to prevent such deaths in the future

The World Health Organisation argues that 80% of all maternal deaths are avoidable deaths. Yet this is an epoch when maternity services in many countries are under significant strain and are struggling to provide safe care. The complexity of reasons that lies behind that stark reality requires profound and rigorous interrogation in many different forums. Our contribution has been a small piece of that complex picture, the public inquest. This landmark Irish legislation, observing in full the rights of women and their families under the ECHR, has changed the public discourse about maternal death and has set a new international benchmark about accountability in tackling the issue of maternal death at source. It has been a very long road for all involved, for the families directly affected most of all, to bring the matter of truth-telling, of parrhesia, to the centre of the tragedy of maternal death. The new act is an act of democratic openness, of simple justice.

We are infinitely grateful to everyone who has made this possible.

Jo Murphy-Lawless, The Elephant Collective


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