A Follow-up Event to Picking Up the Threads, Remaking the Fabric of Care.

In 2019, the Coroners (Amendment) Act became law, having started out as a Private Member’s Bill  introduced by Clare Daly while still a TD. This new law made all maternal deaths subject to mandatory inquests.

The Elephant Collective, a network of educators, artists, midwives and concerned citizens had argued for this change in law through a series of exhibitions across the country from 2015 to 2019, alongside Clare’s work in the Dáil.

Between 2007 and 2021, of thirteen maternal death inquests held, all thirteen returned verdicts of medical misadventure. Of those thirteen women, six were women of colour. Two further inquests will be heard this year, one for Cameroonian Geraldine Yankeu, who died in August 2021, and one for Tatenda Mukwata, originally from Zimbabwe, who died last year.

MEP Clare Daly hosted an exhibition of the Elephant Collective in the European Parliament Building in Brussels in January.

For all of us in the Elephant Collective, the 24th January exhibition and the series of presentations which accompanied it, was a huge moment in which we endeavoured to convey to European parliamentarians what we know about maternal mortality in Ireland, the toll each maternal death takes on everyone it touches and, with rising rates of maternal mortality across Europe, the importance of embedding a thorough legal investigation process similar to ours in each  country in compliance with Article 2 the European Convention on Human Rights.

This is especially important given the sadly increasing numbers of maternal deaths amongst women of colour across EU countries which constitutes a human rights issue. The WHO has noted ethnicity is one of the factors leading to an increased risk of maternal death in health care systems which are troubled by problems of access and safe care.

As the widower of Sally Rowlette, stated with searing clarity on the evening of the 24th January, the impact of still more avoidable maternal deaths following on from the 2019 legislation making maternal death inquests mandatory, is devastating.

We know that inquests can yield critical learning for the prevention of avoidable maternal deaths in the future and we had hoped that mandatory inquests would bring lessons and recommendations back to the Department of Health, the HSE, to hospital groups and to the older voluntary maternity hospitals to help them set in place measures to prevent further avoidable maternal death.

For a complex of reasons, this is still not happening as it should under the 2019 Coroners (Amendment) Act.  

What are we missing? What needs to be done to help the coronial system work more effectively and cohesively in maternal death enquiries, so as to ensure that families and the wider community can have full confidence in it?

One major factor is that coronial recommendations are just that, recommendations; there are no obligatory mechanisms for these to be followed through.

Another major element is that like the rest of the health services, the maternity services are under enormous strain which seriously impedes critical learning.

There are other concerns, not least that the HSE legal services division and alongside them, the State Claims Agency often maintain a stout defence of events in a pregnant or newly-delivered woman’s care leading up to the point of crisis when her life was lost.

While this is perhaps understandable in respect of conventional legal procedures, it means the individual coroner is working with exceptional rigour across complex and often contradictory accounts of what occurred in order to establish a sound coronial verdict, followed by those all-important follow-up recommendations to prevent a similar train of events occurring in the future.

For the inquests themselves, there are a number of important mechanisms at play including the  initiation of internal and external reviews of these catastrophic incidents which may or may not be fully accessible to and part of  the inquest itself.

Those familiar phrases, open disclosure, transparency, and accountability, also come into play when individual hospitals draw back from aspects of the public scrutiny that an inquest, under law, should provide to the families who have lost mothers, wives, partners, daughters. While of course providing accountability to the wider community.

We need to initiate a new public conversation on these matters. As a follow-up event to the recent Brussels event, Clare Daly and the Elephant Collective are hosting a public discussion alongside the exhibition on the 24th March.  We will have the able presence of a panel of practising solicitors and barristers with experience of responding to maternal deaths. Clare Daly will be speaking about the view from Europe on maternal deaths.

The event will be held in Europe House, Lower Mount Street Dublin, on the 24th March from 2.00 to 5.30 pm.

Please see attached invitation. There will be refreshments when the panel discussion has concluded.

RSVP by email to elephantcollective10@gmail.com

For further information, contact:

Dr Jo Murphy-Lawless, Research Fellow, Centre for Health Evaluation, Methodology Research and Evidence Synthesis, University of Galway jo@murphylawless.ie Mobile086 453 4607

Eadaoin O’Sullivan, Parliamentary Assistant to Clare Daly European Parliament clare.daly.brussels@gmail.com

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