CEDH · CASELAW;DECISIONS;ADMISSIBILITY;ENG — 10 novembre 2020

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The President granted the applicant’s request for her identity not to be disclosed to the public (Rule 47 § 4). She was represented before the Court by Mr C. MacGeehin of MacGeehin Toale Solicitors, a lawyer practising in Dublin. 2.     The Irish Government (“the Government”) were represented by their Agent, Mr P. White of the Department of Foreign Affairs and Trade. The circumstances of the case 3.     The facts of the case, as submitted by the parties, may be summarised as follows. The birth of the applicant’s first child 4.     In 1963 the applicant was pregnant with her first child. The expected delivery date was believed to be 7 September 1963, although this was later shown to be erroneous. 5 .     On 18 September 1963 the applicant was admitted to the Coombe Hospital in Dublin, her baby apparently overdue. The Coombe Hospital was, at the time, neither managed nor owned by the State but did benefit from state funding. 6.     The applicant signed a form stating “I give my consent for any operation or anaesthetic which may be necessary”. She subsequently underwent an x-ray pelvimetry which showed that the sub-pubic arch was narrow; the transverse diameter, stated as “normally” being 13.5   centimetres, was 10.8 centimetres; and, while the foetus was small, there was some cephalo-pelvic disproportion (disproportion between the size of the baby’s head and the mother’s pelvis); and the “outlet was diminished”. 7 .     The applicant was examined under anaesthesia on 25 September 1963. During this examination, it was noted that “the head could not be made to engage in the pelvis. Symphysiotomy performed”. 8.     A surgical symphysiotomy involves partially cutting through the fibres of the pubis symphysis (the joint uniting the pubic bones) so as to enlarge the capacity of the pelvis. The procedure allows the pubis symphysis to separate so as to facilitate natural childbirth where there is a mechanical problem. Although the symphysiotomy was recorded in the applicant’s medical records (see paragraph 7 above and paragraph 31 below), she submits that at the time she did not know that the procedure carried out on 25 September 1963 was a symphysiotomy. However, she recalled feeling that she had been “split open” or “split in half” immediately following the procedure, and feeling unstable when walking. 9.     Twelve days later, on 7 October 1963, the applicant’s daughter was delivered vaginally with the assistance of forceps. She claims that as she was still recovering from the symphysiotomy she was physically unable to look after her daughter and had to rely on friends and relatives for assistance. As a consequence, the applicant claimed that she was unable to bond with her. 10.     In the years that followed her daughter’s birth, the applicant claimed that she suffered from back pain, hip pain, urinary incontinence and a number of psychological problems, all of which she attributed to the normal complications of childbirth. 11.     The applicant gave birth to a second child in December 1968. The use of symphysiotomies in Ireland 12.     Symphysiotomy was first introduced in the eighteenth century for selected cases of obstructed labour. Although its use continues to be indicated in certain specific situations, by the mid-twentieth century it had largely been abandoned in Western Europe, due, in large part, to the fact that caesarean sections had become much safer. In the 1940s, however, the practice was reintroduced in certain Irish maternity hospitals and it continued to be used there, to varying degrees, until, in some cases, the mid-1980s. 13.     Concerns regarding the previous use and long-term effects of symphysiotomies in these maternity hospitals emerged in 2001. Many women who had undergone symphysiotomies reported chronic health problems which they attributed to the procedure. Moreover, some argued that there was a strong correlation between the use of the procedure and the acceptance of Catholic doctrine regarding sterilisation and contraception. Family numbers at that time were often relatively large and multiple caesarean sections were not recommended (see paragraphs 33 and 54 below). It was therefore suggested that symphysiotomies were favoured over caesarean sections because – at least in cases of mild to moderate disproportion – a symphysiotomy would enable subsequent children to be delivered vaginally. A caesarean section, on the other hand, would not address the underlying problem and some women, faced with the possibility of repeat sections, might resort to contraception, the sale of which was only legalised several years after a Supreme Court judgment in 1973. 14.     In the 2000s patient advocacy groups called for an independent inquiry into the use of symphysiotomies in Irish hospitals from the 1950s through to the mid-1980s. No review was carried out at this time. There were two attempts to commission reports to evaluate the practice, but in each case the reviewer(s) withdrew from the project, due either to concerns about partiality or to disagreements over the scope of the review. 15 .     Following a meeting in late 2003 between the Minister for Health and a patient advocacy group, the Health Service Executive put in place a support system for women who had undergone symphysiotomies. This included the appointment of regional liaison officers to meet with the women to discuss their healthcare needs; the issuing of General Medical Service cards providing women with access to free healthcare, regardless of means; a refund of any medical expenses directly related to symphysiotomy; and the organisation of individual pathways of care, including gynaecological, urological and orthopaedic assessment, a home assessment by an occupational therapist or physiotherapist, the fast-tracking of applications for home help and home modifications, and the provision of physiotherapy, reflexology, acupuncture and counselling. 16 .     On 18 February 2010 a television documentary (“Primetime”) revealed that in the second half of the twentieth century some 1,500   symphysiotomies were performed in Irish maternity hospitals. A second documentary about the use of symphysiotomies (“Tonight with Vincent Brown”) aired in June 2011. 17 .     In 2010 both the Medical Missionaries of Mary (who were responsible for the Hospital of Our Lady of Lourdes in Drogheda, one of the maternity hospitals in which the procedure had been most frequently employed) and the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians in Ireland issued apologies to anyone who suffered hurt or complications as a result of a symphysiotomy. Representatives from the Institute have since met with some mothers and their families to talk through their experience of the procedure. 18.     In 2011 the Department of Health commissioned a report by Professor   Oonagh Walsh, at the time a Senior Research Fellow in Medical History in the School of History at University College Cork (see paragraphs 52-65 below). According to the terms of reference, the purpose of the report was to document the rates of symphysiotomy and maternal mortality from 1944 to 1984 and, in particular: to assess symphysiotomy rates against maternal mortality rates during that period; critically appraise international reviews of symphysiotomy practice and associated rates in a number of comparable countries and in Ireland; review any guidelines and protocols that applied in Ireland on symphysiotomy over the time period; and write a report based on these findings, providing an accurate picture of the extent of the use of symphysiotomy in Ireland, and an examination of the Irish experience relative to other countries. 19.     On 29 November 2013 the Minister for Health appointed Judge   Yvonne Murphy to conduct a non-statutory review with the aim of finding closure for women who had undergone a symphysiotomy procedure (see paragraphs 66-71 below). The terms of reference were to: examine all relevant reports and information relating to symphysiotomy; meet women who had undergone surgical symphysiotomy procedures to assess what, in their opinion, would bring closure for them; assess, in conjunction with the State Claims Agency and other relevant bodies, the relative liabilities of insurers, indemnifiers, and/or other parties in relation to cases pending, or which might arise, as a result of surgical symphysiotomy procedures; and meet insurers, indemnifiers and/or other parties to explore and negotiate a quantum representing a fair contribution towards the fund in order to establish an ex gratia scheme to bring closure on the issue for the women involved. 20.     In July 2014 the Minister for Health announced the establishment of an ex gratia payment scheme offering compensation to women who had undergone a surgical symphysiotomy or pubiotomy in any hospital in Ireland between 1940 and 1990 (see paragraphs 72-87 below). Kearney v McQuillan and North Eastern Health Board 21 .     A symphysiotomy was performed on Mrs Kearney in 1969. It was performed immediately after her first child was born by caesarean section (an “on the way out” symphysiotomy). She was eighteen years old at the time. In 2004 she brought a claim for medical negligence, breach of duty and battery against the hospital, arguing that the procedure that had been carried out without her knowledge or express consent and she had been left with a legacy of problems which had a significant adverse effect on many aspects of her life. She claimed that in the days and weeks after the procedure she had suffered profound pain; as she had been bandaged from her waist to her pelvic area, and could not get out of bed, she was unable to visit her new-born son for six days after his birth; and she had been unable to take care of him and bond with him following his discharge from hospital. In the longer term, she complained of continuous back pain, incontinence, and pain during sexual intercourse. Furthermore, she had been unable to face the prospect of further pregnancies and became depressed and anxious. 22.     The hospital argued that it was severely prejudiced in the presentation of its defence to the claim due to the fact that many of the witnesses, including the consultant gynaecologist, were deceased or their whereabouts were unknown. The High Court found that the question of consent could only be determined having heard the evidence of those who were present when the plaintiff had given her written consent to the caesarean section. Moreover, having regard to the relevant principles under domestic law (see Dunne (an infant) v. National Maternity Hospital at paragraph 44 below), it would be necessary to debate the appropriateness of the procedure in the plaintiff’s case, and that could only be done in light of the actual testimony of the person who carried it out. The High Court therefore struck out the claim on the basis that the hospital would be severely prejudiced on account of the delay, and that there was a real and serious risk of an unfair trial. 23.     On appeal, Mrs Kearney reformulated her claim and contended that the principal issue was that there had been no justification whatsoever for the performance of a symphysiotomy following delivery by caesarean section. 24.     In a judgment of 26 March 2010, the Supreme Court held that the reformulation of the claim removed any prejudice to the Health Board in defending it as it removed any complaint about the manner in which the symphysiotomy was carried out (as opposed to the decision to carry it out at all) and it rendered irrelevant the matter of any missing contemporary records. As a consequence, the claim could be defeated by the defendant if it could establish any circumstances prevailing in 1969 which would have justified carrying out a symphysiotomy and/or by establishing by means of credible evidence some realistic reason for the carrying out of the procedure in the circumstances of the case. 25 .     The High Court subsequently found that there could be no justification whatsoever for the use of the procedure in the plaintiff’s case as her baby had already been delivered when the symphysiotomy was performed. Moreover, there was no evidence of disproportion between the size of the baby’s head and the plaintiff’s pelvis. The caesarean section had been performed because there was a failure in the pregnancy to progress and there were difficulties in the presentation of the baby’s head; however, unlike disproportion, the evidence established that such a presentation was a “phenomenon of first labour” which would be rare in a subsequent pregnancy. On this basis, the obstetrician could not have diagnosed any need for future caesarean operations or inferred that a future pregnancy would not go to full normal delivery. The court awarded the plaintiff EUR   450,000. 26 .     The defendant appealed to the Supreme Court, which delivered its judgment on 11 July 2012. It upheld the High Court’s findings on liability, but reduced the award of damages to EUR 325,000. While it accepted Mrs   Kearney’s truthfulness and credibility as a witness, the court noted that she had, despite her medical problems, carried on a relatively normal life and worked for a period of some twenty-five years. Therefore, without underestimating the very serious nature of her injuries, it considered a slightly lower award more appropriate. The applicant’s claim for damages 27.     According to the applicant, she became aware that she might have undergone a symphysiotomy when a friend telephoned her after watching a television programme about the procedure (see paragraph 16 above). On 20   February 2010 she wrote to the Coombe Hospital to request copies of her medical records. It would appear that she did not provide sufficient information to enable the records to be found because on 23 April 2010 the hospital wrote to her, seeking further details such as her date of birth and her address at the time of her confinement. She did not reply to this letter, but made a further request in July 2011. She received copies of her medical records in August 2011. (a)    Proceedings before the High Court 28 .     The applicant issued a personal injuries summons against the Coombe Hospital on 6 September 2012. She initially claimed damages for personal injury flowing from the management of her labour and/or for the failure to obtain her lawful or proper consent for all procedures carried out in that regard. The defendant hospital raised a plea that the claim was statute barred as it had been issued after the expiry of the two-year time-limit. In the alternative, in view of the fact that the attending doctors and the anaesthetist were deceased and limited medical records were available, it argued that the claim should be dismissed by reason of “inordinate and inexcusable delay”, as a result of which it was “extremely prejudiced” in its ability to defend the action and that there was accordingly a real and serious risk it could not be afforded a fair trial. 29 .     In an effort to avoid the risk that the claim might be struck out (see the Kearney case at paragraphs 21-26 above), the applicant agreed that it would proceed on one issue only: that there had been no justification whatsoever, in any circumstances, for the performance of an antenatal symphysiotomy in her case. 30 .     The judgment of the High Court was delivered on 1 May 2015 following a fifteen-day hearing. At the outset, the judge found that, following the reformulation of the applicant’s claim, it would be possible for the defendant to have a fair trial. He stated: “In the absence of the reformulation of the plaintiff’s case of October 2014, I believe that the defendant would have had a strong, if not unanswerable case on prejudice.” 31 .     In deciding whether the claim was statute barred, the judge observed that a number of the applicant’s hospital notes in the years following the birth of her first child referred to the fact of symphysiotomy by name. Nevertheless, he accepted that she had heard that term for the first time when her friend telephoned her after watching a documentary on television. Although television programmes dealing with symphysiotomy had aired on 18   February 2010 and June 2011 (see paragraph 16 above), he found that, as a matter of probability, the applicant had been contacted by her friend on 18   February 2010, because she had made the first request for her hospital records two days later. He considered, however, that her “date of knowledge” was August 2011, being the date on which she had received her hospital records. Accordingly, he found that the claim had been issued within the two-year statutory time-limit and the hospital’s plea under the statute of limitations had to fail. 32 .     Although the applicant’s General Practitioner records only dated back to 1995, the judge accepted that she had suffered from physical trauma (in the form of some physical instability and incontinence) and psychological trauma as a result of the symphysiotomy, and that she had been very fearful of becoming pregnant again. The judge noted that while “it would be easy to be cynical and associate these complaints with a retrospective belief fostered by associating with the ‘survivors of symphysiotomy’”, the applicant had raised these matters with work colleagues long before legal proceedings were contemplated. That being said, the judge also noted that the applicant had been in regular and constant employment since returning to work in 1964 and, notwithstanding her age, she was still working as a waitress at the time of the hearing. 33 .     Turning to the central question in the case (namely, whether there had been no justification whatsoever, in any circumstances, for the performance of an antenatal symphysiotomy), the judge had no doubt that the procedure would not have been carried out either at the start of the reintroduction of symphysiotomy into Dublin maternity hospitals or after the introduction of “active management of labour” in the mid-to-late 1960s. However, while he acknowledged that prophylactic symphysiotomy was somewhat controversial in 1963, he accepted that in the Dublin maternity hospitals at that time a trial of labour was not always required for a consultant to conclude that a vaginal delivery would not be possible and in those cases a prophylactic symphysiotomy without trial of labour was a reasonable though limited option. In the present case the pelvimetry and the examination under anaesthetic had convinced the treating doctors that a vaginal delivery would not be possible. This view was supported by the defendant’s medical experts, who stated – and the applicant did not dispute – that it was “90% certain” that had she been afforded a trial of labour she would not have been able to deliver without surgical intervention in the form of either a symphysiotomy or caesarean section. Consequently, the judge accepted that the treating doctors had proceeded on a course which they believed was not adverse to the applicant and was safer for her child. He further concluded that given the real fear of multiple caesarean sections, the belief that symphysiotomy was a relatively benign procedure with little by way of adverse sequelae for the mother, and the wide acceptance of symphysiotomy among the leading consultants in the Coombe and National Maternity Hospital, the applicant had not established that the practice had such “inherent defects” that ought to have been obvious to any person giving the matter due consideration. Consequently, he was not satisfied that there had been no justification whatsoever for a symphysiotomy in the applicant’s case. (b)    The Court of Appeal 34.     The applicant appealed against the rejection of her claim for damages and the defendant hospital cross-appealed against the judge’s finding that the claim was not statute-barred. 35.     On 14 October 2016 the Court of Appeal dismissed the applicant’s appeal as it was fully satisfied that there was credible evidence to support the judge’s finding. It confirmed that, by the standards which prevailed in 1963, the prophylactic symphysiotomy performed on her could have been clinically justified. Moreover, the Court of Appeal found that the judge had been entitled, on the evidence before him, to conclude that prophylactic symphysiotomy had been a general and approved practice in a relatively rare group of cases where clinical findings made in advance of labour strongly suggested that the mother could not deliver vaginally without operative intervention, but was likely to deliver vaginally following symphysiotomy. Regarding the question of whether the practice had “inherent defects”, while the court expressed some reservations about the judge’s reasoning, it agreed that the applicant had not discharged the “heavy onus” required to succeed on this ground. 36.     In dismissing the applicant’s appeal, the Court of emphasised that its decision in the case was fact specific: “The fact that the plaintiff in this action failed in her claim relating to a symphysiotomy performed on her in 1963 does not necessarily mean that a court considering the circumstances in which another symphysiotomy procedure was performed on a different patient might not come to a different conclusion.” 37.     It also sought to explain why the applicant had failed in her claim while the plaintiff in Kearney had succeeded. It observed: “In Kearney , the baby had been delivered before the symphysiotomy was carried out. Accordingly, the procedure was not performed to protect the mother and baby from the risks involved in an obstructed labour. In [LF’s] case, where the procedure was carried out prior to the onset of labour, all of the clinical indications suggested that she was likely to have an obstructed labour. Dr [B] and Professor [B] said it was 90% likely that she could not have delivered without a caesarean section or a symphysiotomy. In Kearney , the High Court found no evidence of any obstruction or pelvic deformity likely to cause the patient difficulty in the course of any future delivery. Thus, there could never have been any justification for carrying out a procedure which had the consequential benefit of making the pelvis a little more accommodating on future deliveries ... In [LF’s] case the position was entirely different. X-ray pelvimetry and examination under general anaesthetic provided objective evidence which strongly suggested that [LF] was suffering from mild to moderate CPD. Further, her pelvis was not normal. It was anthropoid in presentation and she also had signs of outlet contraction. The evidence clearly established that [LF’s] symphysiotomy was performed to avoid an obstructed labour and to allow her to deliver vaginally thus facilitating her avoidance of all of the risks that she might otherwise be exposed to in the course of one and probably several more caesarean sections in the course of her lifetime. No such considerations arose in Mrs Kearney’s case. Thus, unlike in Kearney where the procedure was carried out in the absence of any clinical indications that might justify its performance, in [LF’s] case the symphysiotomy was performed for a range of clinical reasons which at the time were generally approved of by those at the very top of the obstetric profession in this country.” 38.     The Court of Appeal allowed the hospital’s cross-appeal. The court found that the applicant’s date of knowledge was 18 February 2010 and not August 2011, as this was the date on which she had sufficient knowledge to connect her injuries to the procedure which she knew had been carried out on her in 1963. As a consequence, the applicant’s claim was also dismissed on the ground that the statutory limitation period had passed by the date of commencement of the proceedings. 39.     The costs of the appeal were awarded to the defendant hospital to be taxed in default of agreement. (c)    The Supreme Court 40.     The applicant sought permission to appeal to the Supreme Court, challenging the High Court’s assessment of the concepts of a “general and approved practice” and “inherent defects”, where the burden of proof lies in medical negligence cases, and how the date of knowledge is assessed with regard to the statute of limitations. The Supreme Court refused the application for leave to appeal on 17 February 2017. It too emphasised the fact specific nature of the Court of Appeal decision: “... it should be stated that the issues identified in the application are fact specific and case related and, accordingly, the decision of the Court of Appeal has no wider implications than as between the parties to this action.” 41.     Noting further that: “There can be no doubt that the practice of symphysiotomy, in general, has attracted much attention in the relatively recent past, including media scrutiny, public discussion and debate in the Dail [Parliament], as well as an examination by the United Nations Human Rights Committee, with many suggesting that an independent inquiry is required so as to provide an effective remedy for those women who have or who intend to pursue this issue legally. As important as this debate might be, however persuasive the argument may present, such is not the gateway to a further appeal to this Court.” The ex gratia payment scheme 42.     The applicant did not apply to the ex gratia payment scheme for an award. She considered that there was no possibility of any acknowledgement of a breach of her rights; the quantity of the awards did not reflect the gravity of the harm inflicted on her; and the application window was unreasonably short. Relevant domestic law and practice Actions in tort 43.     A tort is a civil wrong which causes someone to suffer loss resulting in legal liability for the person who commits the tortious act. The tort of negligence requires proof that there was a duty of care between the plaintiff and the defendant (which involves establishing the existence of a relationship of proximity between the parties such as would call for the exercise of care by one party towards the other), that that duty was breached and that that breach was causative of damage (see, for example, Beatty v.   The Rent Tribunal [2005] IESC 66). 44 .     In Dunne (an infant) v. National Maternity Hospital [1989] I.R. 91 the principles applicable under domestic law to medical negligence actions were set out as follows: “1.     The true test for establishing negligence in diagnosis or treatment on the part of a medical practitioner is whether he has been proved to be guilty of such failure as no medical practitioner of equal specialist or general status and skill would be guilty of if acting with ordinary care. 2.     If the allegation of negligence against a medical practitioner is based on proof that he deviated from a general and approved practice, that will not establish negligence unless it is also proved that the course he did take was one which no medical practitioner of like specialisation and skill would have followed had he been taking the ordinary care required from a person of his qualifications. 3.     If a medical practitioner charged with negligence defends his conduct by establishing that he followed a practice which was general, and which was approved of by his colleagues of similar specialisation and skill, he cannot escape liability if in reply the plaintiff establishes that such practice has inherent defects which ought to be obvious to any person giving the matter due consideration. 4.     An honest difference of opinion between doctors as to which is the better of two ways of treating a patient does not provide any ground for leaving a question to the jury as to whether a person who has followed one course rather than the other has been negligent. 5.     It is not for a jury (or for a judge) to decide which of two alternative courses of treatment is in their (or his) opinion preferable, but their (or his) function is merely to decide whether the course of treatment followed, on the evidence, complied with the careful conduct of a medical practitioner of like specialisation and skill to that professed by the defendant...” 45.     Section 3(1) of The Statute of Limitations (Amendment) Act 1991, as amended by section 7 of the Civil Liability and Courts Act 2004, introduced a limitation period of two years from the date on which the cause of action accrued or the date of knowledge (if later) for actions for damages in respect of personal injuries caused by negligence, nuisance or breach of duty. Actions for breach of constitutional rights (constitutional tort actions) 46.     In Meskell v. CIE [1973] IR 121, the Supreme Court stated: “... if a person has suffered damage by virtue of a breach of a constitutional right or the infringement of a constitutional right that person is entitled to seek redress against the person or persons who have infringed that right.” 47.     In Ireland, there is an unenumerated constitutional right to bodily integrity. 48.     The limitation period for bringing an action for damages for breach of constitutional rights is six years ( McDonnell v. Ireland [1998] 1 IR134). The European Convention on Human Rights Act 2003 49.     Section 3 of the 2003 Act provides as follows: “(1)     Subject to any statutory provision (other than this Act) or rule of law, every organ of the State shall perform its functions in a manner compatible with the State’s obligations under the Convention provisions. (2)     A person who has suffered injury, loss or damage as a result of a contravention of subsection (1), may, if no other remedy in damages is available, institute proceedings to recover damages in respect of the contravention in the High Court (or, subject to subsection (3), in the Circuit Court) and the Court may award to the person such damages (if any) as it considers appropriate.” The interrelationship between tort law, the Constitution and the European Convention on Human Rights Act 2003 50.     Resort to constitutionally created torts and the 2003 Act only occurs if there is a gap in existing tort law which needs to be supplemented. In DF   v   Garda Commissioner (no 3) [2014] IEHC 2013 (App. 10) the applicant had brought actions in tort for assault and false imprisonment; constitutional claims; claims under the 2003 Act; claims under the Charter of Fundamental Rights of the European Union; and claims under the United Nations Convention on the Rights of Persons with Disabilities 2006. The defendants contended that some of these claims should be struck as either unsustainable in their own right or as otherwise merely replicating claims for damages in respect of the nominate torts of assault and false imprisonment. In response, the High Court Judge indicated that “if the claims simply duplicate or cannot add anything to the well-established nominate torts of false imprisonment, assault and battery or if they present no justiciable issue, I propose to strike them out pursuant to the courts’ inherent jurisdiction at this preliminary stage.” 51.     The judge accepted that a complaint of a breach of the constitutional right to liberty added nothing to the claim for false imprisonment, but considered it possible that the nominate torts of assault and battery would insufficiently vindicate the constitutional rights to the integrity of the person. However, in the circumstances of that case the claim based on Article 3 of the Convention was struck out as it was considered that it added nothing to the existing claims for damages for assault and battery as well as to those for breach of constitutional rights. Relevant public investigations into the use of symphysiotomy in Irish maternity hospitals The report by Professor Oonagh Walsh (“the Walsh report”) 52 .     The Walsh report, which was commissioned in 2011 and published in 2014, was prepared in two phases. The first phase was an independent academic research report, compiled with reference to printed sources and analysis of medical reports and research. Once that was completed, the second phase involved interviews with individuals directly involved in symphysiotomies, such as mothers, practitioners and midwives. (a)    Phase one 53.     A draft of the first phase of the report was delivered in June 2012. It noted that while symphysiotomies might have been more prevalent in Ireland than in other countries during the relevant period, it was nevertheless a rare intervention in comparison to caesarean sections, which rose steadily during the same period. The suggested figure of 1,500   symphysiotomies between 1944 and 1992 translated to a rate of 0.05   percent of total births, or 60 per 100,000 births. In comparison, caesarean sections accounted for just under two percent of deliveries in 1944 and over four percent in 1984. 54 .     The report acknowledged that Irish obstetrical practice was heavily influenced by, and constrained within, a religious framework which was widely accepted by doctors and laypeople alike. The revival of symphysiotomy – a procedure which appeared to offer the possibility of safe repeat deliveries – therefore had to be considered within a context in which multiple births were the norm, artificial contraception and sterilisation were illegal as well as “ethically unacceptable”, and repeat caesarean sections were believed to carry great dangers. Indeed, the lack of options in the control of fertility was acknowledged to be one of the key factors behind a return to symphysiotomy in the 1940s. 55.     The 2012 report further noted that symphysiotomy was statistically a far safer procedure than caesarean section, with lower maternal and foetal mortality rates. At the relevant time the economic situation of many Irish families was “dire” and the Dublin hospitals in particular served areas of significant deprivation. Poor diet and nutrition was not only a common cause of contracted pelvis, but it resulted in many women presenting in labour with other complications that made them poor candidates for general anaesthetic. Moreover, up until the 1960s there were concerns about the safety of repeat caesarean sections. Irish obstetricians – like their Western-educated colleagues – were trained to the so-called “three caesar rule” and believed in the saying “once a caesar, always a caesar”. In Britain, it was common to perform several sections and then advise the mother either to be sterilised or to use artificial contraception. This was not an option in Ireland. 56.     According to the report, the indications for symphysiotomy remained generally constant over the review period (being mild to moderate disproportion). From the outset, therefore, it was viewed as a means of coping with this very specific cohort, and was never proposed as an alternative to caesarean section. The fact that it was more prevalent in some hospitals than in others was due in large part to the fact that some obstetricians had greater faith in the procedure than others. 57 .     The report considered that the use of symphysiotomy as a prophylactic procedure (either in advance of labour or even, in the case of the “on the way out” symphysiotomy, in advance of a further pregnancy) was a deviation from good practice as the degree of disproportion could only be evaluated during labour, and a woman diagnosed with disproportion in one pregnancy might have a normal delivery in the next. In Professor   Walsh’s opinion, the non-emergency application of symphysiotomy, while the mother was under general anaesthetic, appeared “indefensible”. No scientifically credible research proposed prophylactic symphysiotomy or any equivalent to symphysiotomy “on the way out”. Furthermore, while there were no clinical guidelines governing the use of symphysiotomy in Irish maternity hospitals at the time, the generally accepted policy appeared to be to first perform a trial of labour. 58.     With regard to the long-term effects of the procedure, Professor   Walsh was in no doubt that some women had suffered adverse consequences, some of which may have been exacerbated by having more children. She noted, however, that it was difficult to assess the long-term problems resulting from symphysiotomies as many of these were similar if not identical to the long-term complications of multiple pregnancies. 59 .     On the issue of consent, the report noted that during the period under review there were no guidelines in Britain or Ireland for obtaining consent to medical procedures and during the 1940s and 1950s implicit or explicit consent was not required for medical interventions. Indeed, the report described an “overwhelming culture of deference that militated against patient engagement”. Moreover, it would be impossible to determine from this historic distance whether patients were informed when a symphysiotomy was about to be performed or if they were made aware of potential long-term health risks. Given the hierarchical nature of medical practice in the 1950s and 1960s, however, Professor Walsh accepted that it was unlikely that patients were consulted to any significant degree. 60.     The report noted that the use of symphysiotomy had gone into increasing decline from the early 1960s due to improvements in maternal health, increasing use of repeat lower section caesarean sections, increasing use of drugs to shorten labour, and a growing realisation that pelvic disproportion had been over-diagnosed. The report did, however, give special consideration to Our Lady of Lourdes Hospital in Drogheda, where symphysiotomy persisted twenty years after it had largely ceased elsewhere. It found that this was specifically linked to the tenure of the founding obstetrician, who was obeyed by management and nursing staff “without question”. He created an ethos which was “unswervingly Catholic” and was a firm believer in carrying out symphysiotomies in the hope of avoiding caesarean section. According to the report, it was “unacceptable” that the procedure had persisted for so long at this hospital when alternative methods were available for dealing with difficult deliveries. (b)    Phase two 61.     Following her interviews with persons affected by symphysiotomy, Professor Walsh considered that by far the greatest sense of disquiet related to the lack of knowledge regarding the procedure. In particular, there was a strong and widely held feeling that an explanation why a symphysiotomy was being performed in their case would have substantially eased patients’ subsequent adjustment to any resulting physical and psychological problems. Without exception, the most favourable outcomes had been recorded in those cases where either the symphysiotomy had been discussed with the obstetrician beforehand, or when women were told what the procedure was and why it had been used in their cases. By contrast, the women who reported the worst outcomes were those who had not been consulted in advance and were not informed after their deliveries that a symphysiotomy had been performed. Almost twenty percent of respondents had not been told that a symphysiotomy had been performed, and these new mothers could not understand why their recovery was so different from that of other women. 62.     Another important theme that came out of the interviews was the wide divergence in the standard of aftercare, which impacted significantly upon long-term health outcomes. Women who were adequately bound, given bed rest and pain relief, and allowed to become mobile gradually after delivery reported the best immediate and long-term outcomes. However, despite the fact that the importance of bed rest was commonly known in the 1950s, many respondents were told by nursing staff to get out of bed and walk within a day or so of delivery. Many were also discharged from hospital with no guidance or support to ensure proper healing. In Professor Walsh’s view, instructing a newly delivered mother who had just undergone a symphysiotomy to walk without support was an “incomprehensive failure in duty of care”. Moreover, the resulting instability led to long-term side effects for some women, and even to the incorrect fusion of the pelvis, leaving them with chronic pain and locomotive problems. 63.     The most significant difficulties reported in the aftermath of the procedure were chronic pain, difficulty walking, and problems with continence. Many of these were the same as those experienced following a normal but difficult labour, a fact which prevented many women from asking the questions that might have revealed that they had had a symphysiotomy, and from seeking additional specialist care. 64.     The report also considered the impact of symphysiotomies on husbands and children. Many women noted that they had experienced difficulties bonding with their babies, which was exacerbated by the fact that they were often unable to nurse or hold them while they were recovering from the procedure. Husbands were also affected, having to play a role in childcare after deliveries and, for the most part, being ill-equipped to deal with the complications that their wives were experiencing. Symphysiotomies also had an impact on many couples’ sexual relationship, for two principal reasons: first, sex was often painful because of pelvic instability; and secondly, there was a great fear of falling pregnant again. 65 .     Finally, in respect of redress, the report recommended the establishment of an independent specialist needs assessment team to evaluate individual cases, advise on care requirements and determine suitable levels of compensation. The report by Judge Yvonne Murphy (“the Murphy report”) 66 .     In her report published in 2014, Judge Murphy acknowledged that although symphysiotomy had been “an exceptional and rare intervention in obstetric practice in Ireland”, many of the women who had undergone the procedure did not have good experiences. She noted that at the time more than 150   women had instituted proceedings in the High Court and significantly more cases could follow. Such proceedings were, however, fraught with difficulties for both plaintiffs and defendants. A large percentage of plaintiffs were between 75 and 91 years of age and their ability to pursue actions through the courts was limited. In addition, given the passage of time and the nature of their complaints they might face significant difficulties in establishing liability. 67.     First of all, the issue of consent was problematic. If a court decided that a procedure was wholly unnecessary or inappropriate, the question of consent would be irrelevant, but if a symphysiotomy was clinically indicated and within acceptable medical standards at the time, the courts would then have to decide if there had been lawful consent to the procedure. In emergency situations it may not have been possible to obtain consent, and the central question would then be whether a caesarean section ought to have been performed instead of a symphysiotomy. In non-emergency cases consent should have been given. At the relevant time, however, the practice of obtaining consent would have differed from obstetrician to obstetrician and any discussions were unlikely to have been recorded. During the relevant time period it was not unusual for women to be unaccompanied during labour and with the passage of time, and the death of many of the obstetricians and nursing staff concerned, it would now be all but impossible to make any useful inquiry into the issue of consent. As the inability to counter allegations of a lack of consent would place the defendants at a significant disadvantage, they could therefore seek to have the proceedings struck out on the grounds that the defence was irreparably compromised. 68.     Secondly, there was the issue of causation. Even if the absence of consent could be established, the plaintiffs would also have to show that if they had been given the appropriate information, they would have decided against the procedure. 69.     The report also considered the problem defendant hospitals were facing regarding insurance. The passage of time had left many hospitals unable to identify the relevant insurers and, even if they could be traced, the limits of indemnity were in many c