European Parliament, Brussels

24^th  January, 2023

Responding Ethically

Kevin Ryan, our artist who has done the charcoal portraits of Tatenda Mukwata, Geraldine Yanku, and Nayyab Tariq, and Martina Hynan, our artist who did our first eight portraits, all on the walls here tonight, have given us something extraordinarily important: the portraits take us immediately to the depth and the vitality of 11 women who never came home from hospital to their families.

In all our exhibitions across Ireland until the Coroners Act 2019 was passed in full, people came and stood as you are standing now, absorbing the quietness of vital lives lost. 

And an empty bed.

Avoidable maternal deaths.

In March, 2010, my then third year midwifery students came back from their clinical placements in hospital to class. They looked absolutely destroyed. I asked them ‘Whatever has happened to ye?’  and they told me of a woman who had died the previous week in the Rotunda Hospital, a beautiful Nigerian woman, Bimbo Onanuga. They knew there needed to be an inquest,  but none was to be held. 

I am a sociologist, a social theorist who teaches about complexity and ethics in our contemporary world: you cannot stand in front of a room of third year student  midwives on receipt of such news and do nothing.

The first action was to write to the then Master of the Rotunda Hospital to ask him:

• When was an inquest going to be held
• And to remind him that the Nigerian community in Dublin would want and need to know why Bimbo had died

The next set of actions was two-fold:

-To begin to raise the spirits of the midwifery  students by asking each of them to knit a square for a .  .whatever it was going to be, perhaps a tiny wall hanging?

-And to see to the steps needed to get an inquest for Bimbo whose death certificate had been issued stating death by natural causes. In the most basic of senses, this was not exactly incorrect, but actually, it explained nothing of how Bimbo, a healthy young woman, had died. As with all the other women here before you, many decisions had been made within our Irish maternity hospitals and units, with actions either wrongly or mistakenly undertaken, or entirely neglected, all of which led up to a tragic and avoidable death. It was that intricate train of events that needed to be put in its entirety before the coroner’s court, a public space which belongs to all of us and which is not subject to the dissembling of institutions and their senior echelons who have “chosen the security of a life where the truth goes unspoken” (Foucault, 2001:17).

It took two years before it was granted, but we got Bimbo’s inquest. With the help of a fabulous legal team working pro bono, six international expert opinions, and one of Ireland’s finest ever coroners, Dr Brian Farrell. Held in 2013, the inquest concluded with a verdict of medical misadventure, the same verdict which was followed by a string of similar others. Altogether from 2007 to 2021, thirteen inquests, thirteen verdicts of medical misadventure (one a contested verdict settled in the High Court). 

In 2014, a hard year of three inquests, The Quilt began to take shape. We had conjurers along the way: Mary Smyth who conjured up the Elephant Quilt border, and Eadaoin O’Sullivan,  Clare Daly’s parliamentary aide de camp, who dug out a never enacted older version of a coroner’s bill, dusted  it free, and wrote it up as a private member’s bill submitted by Clare to gain mandatory inquests for ALL maternal and late maternal deaths, with free legal aid for the  families so affected. A publicly accountable, completely, transparent open courtroom setting with full disclosure of all documentation from the hospitals involved.

The day a money order was refused for this private member’s bill, Eadaoin raced over to the office of the Minister for Justice and Frances FitzGerald  gave her word that she would take it on as a government bill. And was as good as her word.

As the Elephant Collective, we inundated Clare and Eadaoin and Liz Cassin with work and hundreds of parliamentary questions. They never ONCE said no to us. There was that great gift of trust and generosity  from the outset and it buoyed the spirits of my students, now midwives working in less than safe conditions to support women in heavily overburdened  health systems.

This evening, you have seen the impact of maternal death on families through the eyes of Ayaz Ul Hassan and Sean Rowlette, the horrific consequences of these overburdened systems.

The impact on junior hospital staff, the scarring, is permanent there too – too often they have been left helpless in the face of an encroaching tragedy, minute by minute unable to do what is imperative. A woman’s death in a maternity hospital casts a dread chill and in its aftermath, many staff leave, both midwives and junior medics alike, unable to deal with their personal hopelessness in the wake of these preventable tragedies.  

Fifteen exhibitions across the country by the Elephant Collective between 2015 and 2019. Many conjurers- the artist Gypsy Ray who could see as an artist and said we had to use a bed for the Quilt, the bed to which a mother never returned, Anne-Marie Green who made our documentary on the proceeds of a small cake sale to pay for her petrol.

So many conjurers, Mary Howard who having seen one of the exhibitions in Ennis curated by Martina marched into Clare County Council to their next meeting  and got a  motion passed to support the bill, Doreen Fitzmaurice who was a whirlwind of energy working with community groups across the country, people from  Wexford to Letterkenny.

In 2010, I promised my students practical political hope.  

This project has done this precisely. All of us, my former students too, have learned so much about acting politically, decisively, ethically.

And the passing of the 2019 legislation has put us, Ireland, in line with Article 2 of the ECHR, observing the right of families to a fully independent, investigative rigorous legal investigation into an unexpected death. There is much to be done, coroners with insufficient resources but they still mounting inquests.  Critically, we have to see far greater use of Section 24 by all coroners: we need full disclosure of all documentation from hospitals too frightened to divulge, from state legal agencies too concerned about lying low and not taking responsibility for this loss of life.

You also see before you tonight, the evidence of the disproportionate numbers of women of colour dying in our maternity services.

In 1999, a senior public health doctor in what was then the ERHA asked my colleague Patricia Kennedy and myself to undertake the first study on the maternity care needs of women seeking asylum in Ireland. The circumstances they faced were woeful. When a doctoral student of mine did a similar study in 2008, conditions had worsened. And they have continued to deteriorate. There is rarely space or room for adequate support, let alone best quality support for women within our current dysfunctional maternity services.

In 1992 we had 39 people seeking asylum in Ireland. By 2000, the numbers that year were 10,938. Even without the impact of the Ukraine War in this last year, they were almost 60,000 come to Irish shores.

Internationally, we have gone from the mid-1970s, when it was roughly estimated that  2.5 million people  claimed refugee status, to 15 million in 2000.

It is currently estimated at 82.4 millions.

This is what our globalised neoliberal economy has done at its lower reaches: from poverty to human rights abuses to environmental destruction to wars. This floodtide of migration we have created, this desperate and appalling displacement of peoples will not end any time soon.  Women of childbearing age have pressing needs amidst these conditions of losing one’s original home.

We, YOU as parliamentarians must do the hard work of investigating, calling out, and tearing down the structures which are delivering indifferent to poor maternity care that is ending in higher and higher rates of maternal mortality across Europe. Your focus must be on protecting ALL the women who come to our shores, be they refugees, be they called migrants. They are ALL citizens of the world.

The usual gatekeepers and holders of power in the petty fiefdoms of state administrations and health systems notwithstanding, I beg you to challenge them, as we have done in Ireland.

The Elephant Collective has never been funded by any external agency; we do not have funding, we are not a voluntary organisation. We are but a loose network of concerned citizens – this has been from the very outset about responsive citizen action. Those of you here who are parliamentarians and administrators, I beg you to learn from our example, and to cut through the swathe of irrelevant regulations and boundary keeping meant to resist and confine rather than to expand and protect.

This is about Fearless Speech and Fearless Action. Just as Ayaz and  Sean have spoken to you fearlessly through all their pain, I beg you to go by their courageous example, and to listen to what Hannah Arendt wrote after the Holocaust, as the thinking on the European Convention on Human  Rights was taking shape:

‘Human beings ..are.. capable of telling right from wrong even when all they have to guide them is their own judgement, which moreover, happens to be completely at odds with  what they must regard as the unanimous opinion of all those round them.. [as it was in the camps] Those few who were still able to tell right from wrong went really only by their own judgements, and they did so freely; there were no rules to be abided by..because no rules existed for the unprecedented” (Arendt 1963).’

I beg you to have courage and to act in the face of the unprecedented. 

24^th January, 2023

Dr Jo Murphy-Lawless, Research Fellow

Centre for Health Evaluation, Methodology Research and Evidence Synthesis

University of Galway