Elephant Collective Briefing Paper June 2022
The death of Tatenda Mukwata and the conclusion to Karen McEvoy’s inquest
On 21 April 2022, Tatenda Mukwata died in University Kerry Hospital very soon after giving birth to her fourth child. Her baby girl survived and is healthy. Tatenda, in her early 30s, had been living with her three older children in Atlantic Lodge Direct Provision Centre, Kenmare. She was from Zimbabwe and along with her children had recently been granted leave to remain. She worked locally in an old people’s home, had done a pre-nursing course, and hoped to study nursing as a mature student. At her widely-attended funeral in Kenmare she was praised as a wonderful mother who had the gift of caring and who was a vibrant member of the local Kenmare community.
On 29 April, 2022, the Covid-delayed inquest for Karen McEvoy concluded with a verdict of medical misadventure. Karen was 24 years old when she died from septicaemia and multiple organ failure on Christmas Day, 2018, a scant week after she had given birth normally to her third child, a girl, in the Coombe Women and Infants University Hospital, and been discharged as well on the 19 December, 2018.
The inquest heard that Karen, feeling increasingly unwell with pain in her abdomen, attended a PHN appointment in Naas Vista Primary Health Care Clinic on 21 December 2018 where she reported that she was feeling very unwell. She was told that it was ‘normal’ to feel abdominal pain after birth. The inquest also heard that the PHN did not record any vital signs from Karen as she had no thermometer and no sphygmomanometer (Mother (24) died as a result of medical misadventure, inquest finds – The Irish Times ). The PHN also failed to record that Karen had reported having any pain.
Two days before she died, on 23rd December, 2018, Karen attended the Coombe for a baby appointment and then self-referred to the emergency section of the Coombe Hospital, by then needing crutches to walk and unable to sit down, given the pain she was experiencing. She was not physically examined, none of her vital signs were taken, no urine sample was attempted although Karen reported the key information – in light of how puerperal sepsis progresses – that she could not go to the toilet. Instead, a so-called ‘oral assessment’ was carried out by a midwife in a crowded triage room described as the ‘size of a broom cupboard’ and without seeing Karen, the junior doctor on duty advised the midwife to tell Karen to attend at Tallaght University Hospital if her pain worsened. There was no written record whatsoever of this ‘oral assessment’ nor was there any transfer letter given to Karen for Tallaght Hospital.
At the High Court case in November 2021, which preceded the inquest, a lengthy list of missed chances to properly diagnose Karen’s dangerous condition of post-natal sepsis and a lack of adherence to HSE protocols on treatment of sepsis was laid before the court.
At the conclusion to the settlement of the High Court case, which Barry Kelly, Karen McEvoy’s widower had taken against the Coombe Hospital for catastrophic failures of care leading to Karen’s death, he stated that her death was ’completely preventable’ if she had received proper care and treatment:
‘Instead, she was wrongly diagnosed with sciatica when in fact she had sepsis’ (quoted in Irish Times, 23 November 2021 Coombe apologises over ‘failings in care’ of mother who died of sepsis – The Irish Times )
The detailed circumstances behind these failures, for example, the lack of any equipment whatsoever in the Vista primary health care clinic on the 21st December 2018; midwifery and NCHD staffing levels in the Coombe Hospital on 23rd December 2018 which would have played a critical role in the failure to properly assess Karen, have not been presented for debate in public, for example by a HIQA report laid before the Oireachtas Health Committee.
This data needs to be openly and responsibly presented.
Karen’s inquest verdict of medical misadventure joins a grim list of maternal death verdicts.
Of the thirteen women who died between 2007 and 2020 whose families secured inquests (before the Coroners (Amendment Act 2019, families had to fight to secure inquests the change in law in 2019, making all maternal deaths subject to mandatory inquests; there have been three mandatory inquests since 2019), there have been 13 verdicts of medical misadventure.
Let us repeat that: 13 inquests, 13 verdicts of medical misadventure. Amongst a range of verdicts from which a coroner and a coronial jury can make a determination including an open or narrative verdict, thirteen women died in our maternity services because of negligent care.
These outcomes raise fundamentally serious questions about a system of maternity services whose top advocates claim to be one of the safest in the world.
Six of the 13 women were women of colour and we will return to that crucial point below.
The NMH Controversy
Tatenda’s death, which was written up briefly in two national newspapers, and the conclusion to Karen’s inquest with its verdict of medical misadventure, widely reported on the 28th and 29th April 2022, occurred in the same fortnight which saw intense debate daily in the Oireachtas and the national media, press, television and radio, and social media about the siting of the National Maternity Hospital on the St Vincent’s campus. There were repeated calls to roll back the agreement that the government had signed in a long-drawn out debacle that started in 2012.
In what was a justifiably stormy debate about the legal issues of ownership, governance and clinical control of ‘our National Maternity Hospital’ , given the controlling interests of the St. Vincent’s Healthcare Group, there was a continuing emphasis on the achieving of ‘world class facilities’ in ‘a centre of excellence’ for women in Ireland.
However, these debates, rife with this oft-repeated statement on the part of innumerable government spokespeople, TDs and media commentators debates betrayed a profound ignorance about the current structures of our maternity services, the unreformed and retrograde nature of these structures, the extent to which they are failing women and families, and the absolutely urgent necessity of a serious programme of reform and updating.
The frequent mention of the need to do away with Nightingale wards where women are separated by only curtains and share very limited toilet facilities ( National Maternity Hospital: Statements – Dáil Éireann (33rd Dáil) – Thursday, 12 May 2022 – Houses of the Oireachtas ) avoided stating the realities of how our publicly-funded maternity units and hospitals face pressures to make provision for the resources in their two-tier system to sustain private practice, with full resources for women who pay. This includes state-funded midwives’ pay. The extent of private practice consistently reduces facilities needed for public patients who must then deal with the impact of this competition where women as public patients have very limited choices open to them.
Like Karen McEvoy who was seen in a triage room as big as a ‘broom cupboard’.
Recent controversies like the deficient interview process for the appointment of a new Master in the Rotunda Hospital – Rotunda’s interview panel ‘outrageously old-fashioned’ – Scally – The Irish Times exposed the porous boundary between publicly-funded hospitals and private practice facilities which are part of all 19 of our maternity units and hospitals and which private facilities will be there in the new National Maternity Hospital as well, wherever it is eventually built, all paid for by the state.
The knowledge of the status of Section 38 hospitals under the 2004 Health Act, which include the NMH, the Coombe and the Rotunda is deficient as is an understanding of why there are considerable tensions and fierce resistance to their coming fully under the aegis of the HSE and their determination to retain what they see as their ‘autonomy’ and the chance to make their reputations by developing ‘a very substantial private practice’ in a ‘competitive environment’ (Sam Coulter-Smith, 2022, Delivering the Future, p. 127).
At the end of a lengthy opinion piece on the NMH controversy by Hot Press in May 2022, the journal wrote:
‘in the case of providing private facilities for consultants to generate personal profits, there was very little public knowledge of, or time to consider what is a highly controversial aspect of the [NMH] project’
How could a public debate have overlooked what has been common knowledge for decades about the provision of facilities for private obstetric consultant care?
Private obstetric care is a lucrative source of personal income, and a form of care which is accessed by over a third of women giving birth in Ireland each year in the hope of gaining continuity of carer unavailable to the majority of women in the public system (HIQA, 2020, National Maternity Experience Survey 2020: Report on Maternity Care Provided in the Community by General Practitioners, Practice Nurses, and Midwives). 
The new National Maternity Hospital will continue as a two-tier hospital. It will not be part of a single tier healthcare system as envisaged in Slaintecare.
How could this fact have only just come to light?
During these disconnected debates, how could it be that no TD, no government minister stood on the floor of our Oireachtas and even cited Karen’s and Tatenda’s deaths while they saluting the need for a ‘world-class’ hospital for our ‘world class doctors’?
There is a radical systemic dysfunction that runs throughout Irish maternity services. They lack an overall philosophy, based on up to date international knowledge, evidence, practice. Crucially, they lack truly independent oversight of their activities. They are poor comparators internationally. Individual services are inadequately configured, with poor development of community midwifery services in the antenatal and postnatal periods, far too few home birth services which further suffer from a lack of adequate integration between these and the top-heavy acute hospital services which themselves are poorly articulated and suffer from major staffing issues.
Healthy young women have died as a result of these multiple failures.
The extent of this systemic dysfunction is why the lessons from maternal death inquests are crucial.
Maternal death inquests in Ireland
The campaign for an inquest for Bimbo Onanuga a Nigerian asylum seeker who died following inadequate treatment in the Rotunda Hospital in 2010, ended with the successful granting of an inquest in 2013. That inquest concluded with a finding of medical misadventure. Thereafter a concerted campaign by Clare Daly TD and a committed group of activists known as the Elephant Collective led to a significant change in law, the 2019 Coroners (Amendment) Act, which now requires all maternal deaths to be subject to inquest.
This change in law, in theory, brings the Irish state into compliance with the European Convention on Human Rights, specifically Article 2, the Right to Life.
International human rights law stipulates that states should:
The European Court of Human Rights explicitly refers to these obligations in many of its judgments, including in that of Lopes de Sousa Fernandes versus Portugal; Asiye Genç versus Turkey; Aydoğdu versus Turkey; Calvelli and Ciglio versus Italy; and Mehmet Şenturk and Bekir Şenturk versus Turkey.
These obligations are derived from the duty of states to respect and ensure – inter alia – the right to life as laid down in article 2 of the European Convention on Human Rights; the right to health as laid down in article 12 of the UN Covenant on Economic, Social and Cultural Rights (ICESCR); and the right of women to be free from discrimination in the field of health care as worded in article 12 of the UN Convention of the Elimination of All Forms of Discrimination Against Women (CEDAW).
Besides holding states accountable under the procedural limb of article 2 of the European Convention on Human Rights (for example for lack of an effective and independent investigation into a death in a hospital setting), the European Court of Human Rights has held state parties accountable for deaths (including maternal deaths) that occurred in a hospital setting (and/or were the result of medical negligence) under the substantive limb of this provision in the cases of – inter alia – Asiye Genç versus Turkey; Aydoğdu versus Turkey; Mehmet Şenturk and Bekir Şenturk versus Turkey; and Elena Cojocaru versus Romania.
Under international human rights law states are responsible for the actions of private institutions when – for example – it outsources its medical services and states always maintain the duty to regulate and monitor private health care institutions. The UN Committee on the Elimination of All Forms of Discrimination Against Women – the body overlooking the implementation of the CEDAW – held Brazil accountable for a maternal death in the case of Alyne da Silva Pimentel versus Brazil. It found that ‘the state is directly responsible for the action of private institutions when it outsources its medical services and that furthermore, the state always maintains the duty to regulate and monitor private health care institutions.’ Dr Fleur van Leeuwen, Legal and Human Rights Expert
We hoped this new law would at last bring about the comprehensive transparency and accountability families have long requested.
Instead, what multiple inquests and High Court actions reveal are the consistent and continuing patterns of system failures at multiple levels in our 19 maternity units with no wide-ranging compulsory remedial actions in the wake of inquest findings and recommendations.
In the autumn of 2021, three maternal deaths came to court, two to inquest: Marie Downey and her baby Darragh, Nayyab Tariq, and Karen McEvoy’s case to the High Court. All three continue to raise disturbing issues about the maternity services and the lack of independent oversight.
HSE legal teams and their experts sought to imply, in a continuing pattern we have seen across maternal death inquests since 2007, that the women’s ‘conditions’ – the need for centrally-administered insulin during labour, significantly raised blood pressure, the need for a woman’s specific blood group to be available during a caesarean, carefully monitored epilepsy, concealed intraperitoneal haemorrhage, undiagnosed sepsis – these conditions had taken women to their deaths.
Somehow, it was implied, their deaths had failed the maternity units where all this expertise is gathered together. This lexical drift concealed the stark reality that Nayyab Tariq, Marie Downey, and Karen McEvoy were strong, intelligent, competent, able women who trusted highly specialised services to undertake their care, no matter what untoward or sudden event or emergency might arise.
They were after all in hospitals in a wealthy western country which has the sixth-highest annual expenditure on healthcare out of 33 OECD member states (Casey and Carroll 2021).
In the event, these same highly specialised services failed the women and their families in each and every instance with not one but multiple serious lapses of care leading remorselessly to their deaths.
All three of the recent legal hearings concluded with statements about recommendations which should be implemented, based either on ‘independent’ investigations carried out by Irish obstetric experts or on jury recommendations.
However as with all recommendations which have been made by successive coroners, these are not enforceable and have not been fully followed through by the HSE and by the individual hospitals.
The non-response on the part of a core group of institutional and state actors is marked: this group includes the HSE, its hospital groups, the 16 constituent maternity hospitals/units and the 3 so-called voluntary maternity hospitals in Dublin, the Department of Health, the HSE Legal Services, and the State Claims Agency.
Between 2007 and 2022, of the thirteen cases which have reached an inquest, four deaths centre on sepsis in some form as a principal factor; three have pre-eclampsia/HELLP syndrome, a serious condition that affects specifically pregnant women; three deaths resulted following catastrophic blood loss/internal bleeding; two were post-partum haemorrhages which were poorly identified and never adequately responded to; and one is a catastrophic seizure with neglected care for epilepsy following birth and what was described as a ‘mild’ post-partum haemorrhage.
Bear in mind that these maternal deaths differ radically from maternal deaths in poor world countries where women develop life-threatening complications and die because they have no access at all to modern healthcare facilities or cannot afford transport to the few facilities there are (Ohaja, 2016). In stark contrast, here women’s deaths have happened because of a train of events taking place inside the hospitals of a rich western country. There is a definable medical factor, like sepsis, like HELLP, conditions which a first world hospital system should be fully equipped to respond to as an obstetric emergency.
What needs to be held up to the light of full public examination is how these medical factors have not been responded to until it is too late. We urgently need to know what sequence of events within our hospitals has repeatedly led to a total breakdown of care, beginning with what could and should have been dealt with fully and professionally.
All the thirteen women listed in the Appendix should be alive and leading thriving lives with their families.
After Tania McCabe died in 2007, the HSE did carry out a far-reaching review of the circumstances surrounding her death, and of its 27 recommendations, fifteen were listed as high-priority (HSE 2008). They centred on the identification and early treatment of sepsis and the rapid identification of a woman’s deteriorating condition. The report, requesting implementation of the urgent recommendations, was sent out to all nineteen maternity units. A second report by HIQA on the death of Savita Halappanavar in 2013 should have been a turning point. HIQA personnel, to their credit, had gone back over the ground of the 2008 HSE report and requested updates only to discover that of the 19 maternity units, 5 alone could provide any complete update whatsoever on the progress of the 27 recommendations; of the remaining 14 units, 6 partially reported on their status or made no comment while 6 reported there was no evidence of any implementation.
HIQA reports have no mechanism for enforcement, nor did the 2008 HSE report, nor is there any legal mechanism to enforce coroners’ findings and recommendations. We have no way at present of ensuring that ‘lessons are learned’. Given the brokenness of our maternity services, this means more women will die.
Maternal Deaths of Women of Colour
Especially troubling of the cases which have come to inquest is the number of women of colour who have died in our maternity services. Beginning with Bimbo Onanuga in 2010, we also have Dhara Kivlehan, Nora Hyland, Savita Halappanavar, Malak Thawley, and Nayyab Tariq to which we can with great sadness add Tatenda Mukwate and the young Cameroonian woman Geraldine Yankeu and her baby who died in Cork University Maternity Hospital on August 2, 2021.
When, as a result of the 2019 Coroners (Amendment) Act, Tatenda’s and Geraldine’s deaths come to inquest, we will be looking at 15 maternal death inquests, eight of which involved women of colour.
What does this absolute outsize disproportion of deaths of women of colour to white Irish/caucasian women say about massive institutional deficits in our maternity services including institutional racism?
In the inquest for Nayyab Tariq who died in Mayo General Hospital in March 2020, it was stated that an ‘HSE internal review ‘noted that a key indicator of shock – skin pallor, was initially less obvious due to Ms Tariq’s ethnicity.’ (Verdict of medical misadventure returned in death of young mum who died hours after childbirth – Independent.ie )
It is frankly outrageous that such a specious rationale could have appeared in an official HSE investigation.
In November, 2021, the UK MBRRACE triennial report on maternal deaths (to which the Irish Maternal Death Enquiry submits its figures – see About the Confidential Maternal Death Enquiry | University College Cork (ucc.ie) ) drew attention to the steep disparities in British maternity services where the maternal mortality rates are four times as high for women from Black and Asian minorities compared with white women. MBRRACE-UK: Saving Lives, Improving Mothers’ Care 2021 | Birth Companions
In its foreword, the MBRRACE authors, citing the issue of systemic racism, wrote:
‘We remain deeply concerned that Black and Brown people’s basic human rights to safety, dignity, respect and equality in pregnancy and childbirth are not being protected, respected or upheld.’ From MBRRACE-UK_Maternal_Report_2021_-_FINAL_-_WEB_VERSION.pdf (hubble-live-assets.s3.amazonaws.com)
In May, 2022, the British charity Birthrights, published the results of its year-long research into racism in British maternity care, Systemic racism, not broken bodies An inquiry into racial injustice and human rights in UK maternity care, noting that their findings reveal how systemic racism ‘from individual actions and workforce culture through curriculums and policies’ jeopardises women’s ‘safety, dignity, choice, autonomy, and equality’ https://www.birthrights.org.uk/campaigns-research/racial-injustice/ Birthrights-inquiry-systemic-racism_exec-summary_May-22-web.pdf
The authors point to how this systemic racism costs women their lives and violates Articles 2,3,8,9 and 14 of the European Convention on Human Rights.
Following the inquest for Nayyab Tariq in September 2021, Dr Naomi Masheti, co-ordinator, Cork Migrant Centre noted about our maternal death inquests that:
‘Almost 39% of deaths were among women born outside Ireland, while this group represented just 24% of all women giving birth. The findings raised questions about how these women engage with maternity services.’ Naomi Masheti: Race and ethnicity shouldn’t matter in maternity care. But they do. (irishexaminer.com)
Our figures, the women of colour who have died in our maternity services beg a comprehensive official review of all the factors, including systemic racism, which sent them to their deaths.
What Is Happening, What Needs to Change
There is non-engagement with and often active obstruction of the women’s widowers and families which are a denial of the very transparency and accountability that the Elephant Collective campaign of 2014-2019 sought.
These consistent patterns stand out:
THE ABOVE FACTORS HAVE ALL COME INTO PLAY IN THE DEATHS OF THE THIRTEEEN WOMEN WHICH HAVE COME TO INQUEST
Independent Oversight by HIQA of All Serious Maternity Cases
When Judge Maureen Harding-Clarke published her 2006 review of Neary’s unrestrained practices of hysterectomy over a 25-year period, Inquiry into peripartum hysterectomy at Our Lady of Lourdes Hospital, Drogheda, Ireland, she questioned in forthright terms the culture in the hospital:
‘The findings here were quite extraordinary and difficult to understand. We found an incredibly pervasive culture of acceptance and acquiescence of consultant activity. To ask why, or to comment was not a part of everyday practice. To consider that things could change seemed unimaginable.’ (Harding-Clarke, 2006:155)
Harding-Clarke also drew attention to the three senior obstetricians who initially cleared Neary of any wrongdoing whatsoever with the result that he returned to work (ibid. 4-6), and to the fact that the Institute of Obstetricians and Gynaecologists, the Irish Medical Council and other professional bodies with some degree of regulation had rarely visited the hospital and had observed nothing untoward in Neary’s practice (ibid.:257-272). ’Hidden in plain sight’ (Hynan, 2018) has been a continuing and troubling dimension underwriting the extensive failings of Irish maternity services, given the continuing unquestioned status of obstetric consultants.
HIQA has been an important mainstay in gaining any transparency over catastrophic failures of care in the maternity services, including amongst other key reports, the 2013 report on the failures of care leading to Savita Halappananvar’s death ( Patient Safety Investigation report into services at University Hospital Galway (UHG) and as reflected in the care provided to Savita Halappanavar | HIQA) and the 2015 investigation into failures of care leading to the deaths of babies in Portlaoise’s Midland Regional Hospital (Portlaoise-Investigation-Report.pdf (hiqa.ie).
Rigorous independent investigations are crucial to the comprehensive identification of all the factors leading to these catastrophic failures of care we have all witnessed.
These investigations must be uncontaminated by the sectoral professional interests that Judge Harding-Clark pointed out were at play in the initial reviews of the scandals of non-care which characterised the Neary regime in our Lady of Lourdes Drogheda:
HIQA’s work has also been challenged by HSE and Department of Health interests as well:
Investigatory independence is fundamental to achieving maternity services and HIQA has fulfilled that role on behalf of the Irish public.
It is a matter of considerable dismay, therefore, to discover from the written reply to a recent parliamentary question (Question Number(s): 649 Question Reference(s): 27331/22) that the Minister for Health has sanctioned under Budget 2022 an HSE-based internal investigation team, the so-called HSE Obstetric Event Support Team (OEST) with a budget of €540,000 ‘to provide objective oversight over a specified list of obstetric clinical incidents occurring within Maternity Networks’ including ‘severe maternity related incidents’.
How has such a group, with a substantial budget, to be led by a former Master of the Rotunda Hospital, been set up?
A group which undercuts the independence of HIQA, our statutory body established under the 2007 Health Act with the remit to inspect, review, investigate, and monitor compliance across all our health services and to do so independently.
Hard questions need to be asked of the Minister for Health as to why this new internal body has been established, given HIQA’s statutory obligations and role and why we are effectively being returned to the Neary era where obstetricians investigate themselves.
We urge the following critical steps to be taken to stop this pattern of system failure leading to women’s deaths:
–Encouraging full use of Section 24, Coroners (Amendment) Act 2019
–Full public inquiry on the systemic failures leading to inquest verdicts of medical misadventure for 13 maternal deaths, 2007-2022.
The Elephant Collective, June 2022
Murphy-Lawless, J. (2021) Holding the State to Account: “Picking Up the Threads” for Women Who Have Died in Irish Maternity Services, Éire-Ireland 56: 3 & 4 Fall/Win 21, pp. 51-79. Irish American Cultural Institute. Project MUSE – Éire-Ireland-Volume 56, Numbers 3 & 4, Fall/Winter 2021 (jhu.edu)
Appendix Women who Have Died in Our Maternity Services for Whom Inquests Have Been Held
 In 2013, when then Minister for Health James Reilly announced the establishment of six hospital groups across Ireland, each group was meant to include at least one teaching hospital which would help pursue greater ‘learning’ that was research-evidence based. The now customary language about excellence of governance, outcomes, accountability etc. was at the centre of the press releases announcing these changes. Minister Announces Hospital Groups and Publishes The Framework for Smaller Hospitals | BIMIreland.ie | Ireland’s Only Dedicated BIM Exclusive Resource . It was at this time that the inclusion of the word ‘university’ in the title of many of the HSE group of hospitals became commonplace, as if to reassure people that the name as part of this overall move would lead to a step up in quality.
 The privately-owned Vista facility employing consultants, GPs, and nurses was opened by then Minister for Health Mary Harney in 2009 with a range of HSE-funded services included in its public-private mix €25m primary care campus for Naas (rte.ie). It was meant to ‘save many people in the region the inconvenience of having to travel to Dublin, through the provision of world-class facilities on a more localised basis’ (quoted in Private healthcare centre for Naas – The Irish Times ).
 There was no midwife employed in the Vista Clinic. A number of legislative and administrative barriers, including the unreformed Maternity and Infant Care scheme and the badly outdated GMS contract for GPs, prevents this happening to the detriment of women’s care needs in the antenatal and postnatal periods, given the completely overburdened maternity units within the hospital system. There has also been a continuing problem with PHN qualifications since 2004 when in the wake of the 1998 recommendation by the Commission on Nursing, on grounds of efficiency, the Department of Health chose to drop the requirement to have a full postgraduate midwifery training and replaced it with a short module on maternal well-being during pregnancy and the post-partum period, and also argued that with the exception of a few small pilot projects, community midwifery remained ‘abysmally underdeveloped’ in Ireland compared with neighbouring jurisdictions. See PHNs: Taking midwifery beyond the delivery room (inmo.ie) ; PHN criteria changed without consultation (inmo.ie).
 As the inquest later heard, this ‘advice’ was in breach of the protocols on maternal sepsis. See Maternal Sepsis 3 web (hse.ie) where it states that pelvic pain is one of the red alert symptoms indicating that a woman should be investigated for maternal sepsis. Furthermore in the early postpartum period, a woman reporting such symptoms is not referred to a general hospital unless a very specific non-birth related scan or test is required. Instead the IMEWS national early warning score, first piloted in the Coombe Hospital, is the standard protocol. See Irish Maternity Early Warning System (IMEWS) – HSE.ie and Maternal sepsis – HSE.ie. See also Footnote 13 on the problem of 24 hour consultant cover and Footnote 19 for the IMO statement on the lack of training programmes for NCHDs.
 These guidelines were first issued by the HSE after the death of Tania McCabe in 2007, then repeated and strengthened in content in the wake of Savita Halappanavar’s death and are readily available as downloads in every maternity unit; moreover recognition of sepsis forms part of the emergency obstetric drills which every maternity unit is meant to be carrying out at regular intervals.
 Other women died in this period but their families were unable to gain an inquest before the Coroners (Amendment) Act 2019 made inquests mandatory. There were 24 direct maternal deaths in Ireland between 2009 and 2019 (MDE, 2020). Before the 2019 change in law, we do not have full coronial investigations of causes of death for all 24 women, only what was listed on the death certificate. Cause of death can and is contested at inquest. Ultimately in the death of Tracy Fitzpatrick who died in St Lukes Kilkenny on Easter Sunday 2016, and whose cause of death was listed as amniotic embolism, a High Court case eventually rejected this as cause of death and the HSE admitted instead to catastrophic failures of care which had led to Ms Fitzpatrick’s death.
 Although it was oft-repeated by commentators and TDs during the public debate that this was ‘our National Maternity Hospital, the title ‘The National Maternity Hospital WAS NEVER CONFERRED ON THE HOSPITAL BY THE IRISH STATE; it was a title the founding members of the hospital took to themselves in 1894:
‘The new National Maternity Hospital in Holles Street officially opened its doors on 17 March 1894. The Chairman hit a popular theme when he declared that: “The importance of such an institution could not be exaggerated, and it was for them to see that it was managed for their own Catholic people under Catholic management wholly and solely’’ [as reported in the Irish Times]. The founding members of the new hospital were determined to create a Catholic maternity facility for a largely Catholic population. Neither the Rotunda nor the Coombe were regarded as such’. (Farmar, 1994: 8-9).
 Despite what the 2016 National Maternity Strategy committed to on paper, urgent reforms in line with international best practice, such as the establishment of alongside midwifery-led units and the establishment of a properly functioning network of community midwifery have been shelved. Ireland has only two midwife-led units, compared with Northern Ireland, with a much smaller population, which has 8, and Scotland with a broadly similar population to the Republic which has 17.
 The Rotunda’s newly appointed Master Sean Daly, former Master of the Coombe Hospital is a business partner of the retiring Master Fergal Malone, in a private antenatal clinic in Sandyford. New head of Rotunda maternity hospital is a private practice partner of the outgoing master – Independent.ie
 Marie O’Connor (“Conjuring Choice While Subverting Autonomy: Medical Technocracy and Home Birth in Ireland,” in Risk and Choice in Maternity Care: An International Perspective, ed. Andrew Symon (London: Churchill Livingstone Elsevier, 2006) has analysed the high income-earning potential that accrues to the hundred or so consultant obstetricians working in this dual public-private mix. She estimates that the private care obstetric market is worth some €49 million annually with Dublin obstetric consultants able to command fees of up to €503,000 each per annum, while consultants outside Dublin can average €447,000 each, all in addition to their public salaries (2006:110). Private obstetric care fees are financed via a private health insurance market, with policies taken out by women not stretching to the full extent of costs. Each birth can run from €2,000 to over €4,000 and the individual woman will pay out of pocket for a number of uninsurable hospital expenses (Pope, Irish Times, 2017). For the sake of comparison, an NHS consultant obstetrician, with no private practice whatsoever, but providing 24/7 hospital cover will be earning a top salary of 180,000 euro equivalent.
 A PQ submitted to the HSE in 2016 seeking the total payouts between 2007 and 2015 yielded these figures:
Total damages paid out: €282, 833, 052
Total legal fees paid out: €96, 396, 599
These sums represent a mere 2 percent of clinical activity across all the health services yet consistently incur the overwhelming percentage, over 80 per cent, of legal-medico damages paid out in court.
There is also a problem of behind the scenes conferring between the HSE Legal Services, the State Claims Agency and the sites where investigations and reviews into serious obstetric incidents have taken place (see for example, Hegarty, 2017 Families accuse Portiuncula Hospital of attempted cover-up of maternity failings, RTE News, Tuesday, 25 April, 2017. Families accuse hospital of ‘attempted cover-up’ (rte.ie)
 In 2019, the Irish Medical Organisation issued a report on its concerns that 50 per cent of all non-consultant hospital doctors are working in hospitals without a formal training position. Concern over insufficient training posts (imt.ie)
 One of the underlying issues in the High Court case and indeed in Malak Thawley’s inquest was the absence of 24-hour consultant cover in Holles Street. During this High Court case, Dr Mahony testified that it was not possible to supply such cover ‘as there were insufficient consultants to perform all procedures in the hospital in any 24 hour period’’ (Inquiry ‘would have negative effect’ on Holles Street (rte.ie). It is worth noting that a 2021 cohort study of a large obstetric unit in a regional teaching hospital in the UK reported on outcomes to improve patent safety having successfully implemented 24 hour consultant cover in line with the 2005 RCOG that all units should move to this policy. Moraid et al, 2021: 24_hour_consultant_obstetrician_presence_on_the_la.pdf