Inquests Are Essential To Understanding Maternal Deaths

Posted on: 26 November 2015

By Dr Jo Murphy-Lawless, Sociologist, School of Nursing and Midwifery

Between 2008 and 2014, eight public inquests into the deaths of women who died in Irish maternity units ended with verdicts of medical misadventure. 

Every maternal death – like those of Tania McCabe, Evelyn Flanagan, Jennifer Crean, Bimbo Onanuga, Dhara Kivlehan, Nora Hyland, Savita Halappanavar and Sally Rowlette – is a dreadful tragedy with life-long consequences for the families involved.

On top of their catastrophic loss, families often have to wait for lengthy periods to find out why their wife or partner has died.

There have been intolerable delays in inquests being granted, with bereaved families having to battle for that hearing. Some families have never been granted an inquest. For those who get one, the inquests are critical, as they explain how the deaths happened as well as identifying avoidable factors that contributed to these deaths.

Each woman's death was followed up with an internal review in line with hospital and HSE mechanisms. But the review reports were only made publicly available in two instances, that of Tania McCabe's death, along with her son Zach in 2007, and Savita Halappanavar's death in 2012.

For the remaining families and for the public, an inquest was the only means they had to be fully informed of what had led to their deaths. Recommendations were made by the jury or by the coroner following each inquest about how to prevent similar deaths in the future.

Following all the inquests, assurances were given by the HSE that lessons had been learnt, that clinical and care practices had improved.

Yet if substantive improvements and more secure clinical governance had occurred at local and national levels after the investigations into Tania McCabe's death and that of Dhara Kivlehan in 2010, it is arguable that Savita Halappanavar and Sally Rowlette (2013) might not have died.

In the wake of the unprecedented publicity that surrounded the death of Savita Halappanavar, a ground-breaking HIQA report, published in 2013, found a failure of basic care locally, alongside a national failure to standardise the approach to care and monitoring for women whose circumstances have begun to deteriorate.

For example, there was not even a nationally accepted definition of maternal sepsis, which we had been assured would happen after Tania McCabe's death.

The 2013 HIQA report along with the HIQA report into the Portlaoise baby deaths earlier this year both focus on additional major problems at the heart of our maternity services: the chronic lack of staff numbers, the chronic lack of appropriately skilled staff at senior levels and the failure to improve governance and accountability.

Given these findings, people are right to doubt HSE assurances about greater safety of maternity services.

The mantra from successive Ministers for Health is that Irish maternity services are amongst the safest in the world, if not the safest. Over the years, various statistical sleights of hand have been used to reach that conclusion, including significant non-collection and incomplete collection of data nationally.

The unedifying spectacle earlier this year of one State-funded body, the HSE, threatening to take a second State-funded body, HIQA, to court over the Portlaoise report can only increase the dismay for families who face unexpected deaths in our maternity services. Despite public reassurances, the HSE appears to resist a genuine policy of open disclosure.

Therefore, the inquest process is the one reliable instrument families have to get to the core of what happened.

In 2014, a national maternity strategy group was finally set up to review our services.

We wait to see if the Department of Health has the grit to recommend, and then implement, the radical reform our maternity services need or if vested interests will continue to hold such services in the doldrums.

A maternal death casts a deep chill over the entirety of a maternity unit. Given the legal neutrality of a coroner's inquest in determining how a woman died, staff too would benefit from what we can learn through the inquest process.

We need a change in law to have an automatic inquest in the case of every maternal death.

A multimedia exhibition, 'Picking Up the Threads, Remaking the Fabric of Care' has just opened in St Laurence’s, Grangegorman DIT, Dublin 7, to commemorate the lives of these eight women. For details,