The scandal the State fears – illegal adoptions

The focus on one institution — Tuam — and one issue — baby deaths — has proved to be convenient for the Government but the spotlight needs to shift to the glaring elephant in the room that nobody wants to talk about. The issue will simply not go away.

It’s been just over three years since the Mother and Baby Homes Commission began its work examining 14 mother and baby homes and a selection of county homes.

Despite having terms of reference that include crucial issues like adoption practices and vaccine trials, its focus in that time has been almost exclusively on one institution — Tuam, and one issue — infant deaths.

This may be by accident or design but, either way, it suits the Government. It keeps the narrative focused on historic deaths in an institution in the west of Ireland and away from a key issue — the huge and glaring elephant in the room that no one likes to mention — the scale of forced and illegal adoptions and the State’s role in same.

The irony of all of this is that an inquiry into all of these matters could have happened long before the Mother and Baby Homes Commission was set up in 2015. Like the Magdalene laundries inquiry before it, the Government was dragged kicking and screaming into an investigation.

The research of Catherine Corless relating to infant deaths at the Tuam Mother and Baby Home and the subsequent international media attention the story generated forced the Government to examine these institutions.

We have since learned, through numerous revelations in this newspaper, that the State was well aware of these issues long before Tuam hit the headlines in 2012.

Indeed, calls for an inquiry into how thousands of adoptions have been contracted across decades have been bouncing around since the 1990s. Every government since then has told activists that there is nothing to see here — despite mountains of evidence stating otherwise.

So three years into the inquiry, what has been the progress of the Mother and Baby Homes Commission? In a word — slow.

That was to be expected. No one with a grasp of the scale of the task facing the Commission expected it to issue its final report by the initial deadline of February 2018. It will now issue its final report in February of next year.

However, given it has just recently moved its focus away from Tuam to examining another institution — Bessborough Mother and Baby Home in Cork — this also looks ambitious.

The Commission was established in February 2015. From then until July 2016, very little emerged as to its progress or how it operated.

In that time, a number of investigations by this newspaper revealed that both Tuam and Bessborough had been examined by the HSE prior to Catherine Corless’ revelations.

Senior management in that organisation, as well as two government departments — the Department of Children and Youth Affairs and the Department of Health — had been made aware of serious concerns raised about practices in at least one of these institutions.

In June 2015, just four months after the Commission was set up, the Irish Examiner revealed that two separate reports on Tuam and Bessborough were prepared by the HSE, while it was preparing material for the McAleese investigation into Magdalene laundries.

These reports not only explicitly reference infant mortality rates, but also expressed serious concerns about the possible trafficking of children from the institutions. They also mention that these issues needed to be investigated as a matter of urgency.

In the case of Tuam, a note of a teleconference call on October 12, 2012, revealed that senior management in the HSE felt what had been discovered needed to go to the minister so that warranted a state inquiry.

The call involved then assistant director of the Children and Family Service at the HSE, Phil Garland, and then head of the medical intelligence unit, Davida De La Harpe.

During the call, concern was expressed that as many as 1,000 children may have been trafficked from the Tuam Mother and Baby Home in what could “prove to be a scandal that dwarfs other, more recent issues with the Church and State”.

These concerns had been raised by the principal social worker for adoption in HSE West, who had found “a large archive of photographs, documentation, and correspondence relating to children sent for adoption to the USA” and “documentation in relation to discharges and admissions to psychiatric institutions in the Western area”.

The archive contained letters from the Tuam Mother and Baby Home to parents, asking for money for the upkeep of their children, and notes that the duration of stay for children might have been prolonged by the order for financial reasons. It also contained letters to parents asking for money for the upkeep of some children who had already been discharged or who had died.

The social worker, “working in her own time and on her own dollar”, had compiled a list of “up to 1,000 names”, but said it was “not clear yet whether all of these relate to the ongoing examination of the Magdalene system, or whether they relate to the adoption of children by parents, possibly in the USA”.

Those on the conference call raise the possibility that if there is evidence of trafficking, “it must have been facilitated by doctors, social workers, etc, and a number of these health professionals may still be working in the system”.

The note concludes by stating that, due to the gravity of what was being found, an “early warning letter” be written to the national director of the HSE’s quality and patient safety division, Philip Crowley, suggesting “that this goes all the way up to the minister”.

“It is more important to send this up to the minister as soon as possible: with a view to an inter-departmental committee and a fully fledged, fully resourced forensic investigation and state inquiry,” concludes the note.

At the time, the Department of Children and Youth Affairs (DCYA) denied this information was ever forwarded to the then minister Frances Fitzgerald.

A week later, in a separate report sent by Mr Garland to Mr Crowley, and which CC’d then national director of Children and Family Services, Gordon Jeyes, and Ms De la Harpe, Dr Declan McKeown, of the medical intelligence unit, also outlined concerns about death rates at both Tuam and Bessborough.

Dr McKeown notes that the infant mortality rate for Tuam was “approximately 20%-25%, similar to that recorded in Bessborough”. He also raised questions as to the veracity of such death rates.

“Queries over the veracity of the records are suggested by causes of death such as ‘marasmus’ in a two-and-a-half-month-old infant; or ‘pernicious anaemia’ in a four-month-old. These diagnoses would be extremely unusual in children so young, even with the reduced nutrition of the time,” he said.

A separate report into Bessborough not only revealed that the deaths of hundreds of children were recorded in the order’s own register which was handed over to the HSE in 2011, but that, similar to Tuam, the operation was aimed at making money. This report was seen by both the DCYA and the Department of Health yet no action was taken on foot of the concerns.

It is understood that these revelations and what was known by key personnel within the HSE prior to the 2014 revelations is currently being examined by the Commission.

However, throughout 2015, there was no word emanating from the Commission as to the progress it was making. Indeed, even the most rudimentary of press queries were met with terse responses.

In August 2015, the Commission declined to answer any questions as to how its Confidential Committee — set up to gather testimony from survivors — operates.

The Irish Examiner asked a series of questions:

• Will all interviews with the Confidential Committee be recorded, unless a witness does not consent to this?

• Will a transcript and audio copy of the recording be provided to the witness?

• What is the area of expertise of the experienced person taking notes when a witness is being interviewed?

• Will a copy of those notes be sent to the witness?

• Will the witness have an opportunity to clarify anything s/he believes does not reflect her/his testimony?

• Will witnesses be given a copy of the general report of the Confidential Committee?

However, a statement issued by Commission director Ita Mangan simply said: “All aspects of the Confidential Committee are confidential including its procedures. People who wish to be heard by the committee are given detailed information in advance about how the meeting will be conducted.”

In fact, some information on this Committee was one aspect dealt with when the Commission finally published some information on its progress in July 2016 — well over a year after it was set up. The Commission’s first interim report ran to just five pages and was primarily a request to extend the timeframe for the completion of its Confidential Committee report and its Social History Report. These were due to be submitted in August 2017.

The Commission asked for these to now be submitted along with the overall final report in February 2018.

At the end of September, the Commission announced it was carrying out a test excavation at the site of the children’s burial ground for the Tuam Mother and Baby Home. Site work began in October and was expected to last five weeks.

Then on 3 March, 2017, and somewhat out of the blue, the Commission dropped a bombshell that thrust Tuam back into the worldwide media glare. It confirmed that “significant quantities of human remains” had been discovered in at least 17 of the 20 underground chambers which were examined as part of the excavation works.

The Commission said it was “shocked” by the discovery and that it was continuing its investigation into who was “responsible for the disposal of human remains in this way”.

It requested that the relevant State authorities take responsibility for the “appropriate treatment of the remains” and notified the coroner.

In response, Children’s Minister Katherine Zappone said the coroner for north Galway would take the steps he deemed necessary and stated that Galway County Council would engage with the Commission in relation to the next steps to be taken at the site.

In June, Ms Zappone commissioned an Expert Technical Group (ETG) to outline to Government as to what options were available in terms of managing the burial ground.

Almost a year and a half year later, there has still been no decision made as to what to do with the site.

The reason for the delay is clear. Given it is known, and indeed the State has held the evidence since at least 2011, that similarly high infant mortality rates were prevalent in other mother and baby homes — most notably Bessborough — it would appear that any decision taken at Tuam will have to be replicated in other sites of suspected infant burials.

Delays were also attached to the publication of the Commission’s second interim report.

Completed in September 2016, it was not published by the DCYA until April 2017 — one month after the discovery of infant remains in Tuam.

Running to 16 pages, the report has three main sections — on redress, its terms of reference, and on the issue of the false registration of births.

The Government managed to get its message out ahead of the second interim report’s publication, when the Irish Times reported in advance of its publication the Government’s view that it “not possible” to implement the report’s main recommendation that the 2002 Residential Institutions Redress Scheme be reopened in order to compensate those who were in mother and baby homes as children.

The report stated that the Government should re-examine the exclusion of children who lived without their mothers in mother and baby and county homes from the 2002 scheme and that “other redress options” for those involved.

It stated that former residents of the Bethany Home and other mother and baby homes like Bessborough, Sean Ross Abbey, Castlepollard, Tuam and Dunboyne all had “a strong case” that they should have been included in the 2002 scheme.

“It is clear to the Commission, from its work to date, that the decisions on which institutions to include in, or exclude from, the redress scheme are not consistent,” stated the report.

However, the Government had already got its point across that this option was out of the question. It was repeated by Ms Zappone on the day of publication. The Commission had not yet made any findings to date regarding “regarding abuse or neglect” and it “would not be appropriate” to deal with the question of redress in advance of the final report, she said.

Indeed, successive governments have been aware that the thorny issue of redress for mother and baby homes would arrive some day.

The Irish Examiner revealed in March 2017 that concerns were expressed at Cabinet as far back as 2011 that, if there was an inquiry into Magdalene laundries, it could lead to calls for inquiries into abuses in mother and baby homes, psychiatric institutions, and foster care settings.

The concerns are in a memorandum for Government seeking permission to establish what became the McAleese committee.

The observations of the then minister for education and skills Ruairí Quinn state that, although he was supportive of the approach outlined in the memorandum, “there may be demands for enquiries [sic] into other situations”.

“Following the publication of the ‘Report of the Commission to Inquire into Child Abuse (the Ryan Report)’, there were renewed demands for the Redress Scheme to be extended to include other institutions, such as Magdalene laundries, mother and baby homes, psychiatric hospitals and foster care settings,” he said.

It went on to state that, while Mr Quinn recognised the demands being made on behalf of the women who had been through Magdalene laundries were for a separate redress scheme, “he is conscious of the implications of any move towards redress, for the Residential Insititutions Redress Scheme”.

The Commission’s second interim report acknowledged calls for an extension of its terms of reference to examine private nursing homes/maternity homes and a range of adoption societies but said such a decision could not be made until the current investigation is concluded. At that stage it “may be in a position to make further recommendations”.

Given a major part of its remit is to examine practices in relation to how adoptions were contracted, the second interim reports section on illegal adoption is remarkably lukewarm. In fact, the relevant chapter of the report is titled “False registration of birth” — a rather euphemistic term favoured by government departments. The false registration of birth, which was often facilitated by registered adoption societies, is after all, a serious criminal offence.

The report notes that illegal adoptions cover a “wide variety of situations including actions taken (or not taken) prior to the adoption and illegality in the adoption orders made”.

However, it makes no effort to highlight any of these. Instead, the focus of the section is on illegal birth registrations.

These occurred where the birth was registered in the name of adoptive parents and — crucially, from the State’s perspective — no formal adoption order was ever made.

In short, most of these cases can’t be called illegal adoptions as no formal adoption order was ever granted by the Adoption Board. The State is off the hook.

While the Commission acknowledges that the false registration of a birth is a criminal offence, it speculates that those involved in such practices may have been engaging in a crime for what they thought were the right reasons.

“It is possible that such registrations were carried out for what were perceived to be good reasons (this does not change the fact that it was an offence). Formal legal adoption did not become available in Ireland until 1953.

There is some anecdotal evidence to suggest that, prior to the availability of formal adoption, “adoptive” parents may have falsely registered the birth in the belief that they were conferring legal status on the child.

This narrative, offered without anything other than “anecdotal evidence”, indicates that such activity was done by ordinary, well-meaning couples rather than being facilitated by any other power structure such as a religious order or, indeed, the State.

However, what about the possibility that the opposite of this scenario may also be true? Namely, that such activity may have been facilitated for less than well-meaning reasons?

In December 2017, the Commission published its third interim report. The prime focus of the four-page report was to seek permission to push back the deadline for submitting its final report until February 2019.

However, as with the second interim report, some of the language seemed to seemed to be dampening expectations in terms of what the investigation could achieve.

The key line in the report is the Commission’s belief that it will be “difficult to establish the facts” surrounding the burials of children who died in all of the homes it is investigating.

It noted that that while there are “detailed death records available” in relation to mother and baby homes, there are also “significant gaps” in the information available about the burials of babies who died in a number of the institutions it is examining.

“The Commission is continuing to make inquiries about burials and burial records but it appears that this is an area in which it will be difficult to establish the facts,” stated the report.

Following the publication of the report, Ms Zappone announced other measures which would operate in parallel to the Commission’s work. Most notably, a collaborative forum would be established to support former residents of mother and baby homes. in developing solutions to the issues of concern to them.

One week later, the Government published the findings of the ETG report into the site at Tuam.

As with the second interim report, a very specific element of the report’s findings was leaked to the Irish Times in advance of publication.

This focused on the ETG assertion that it would be difficult to isolate individual remains at Tuam and that the Government should seek to ensure that expectations as to what is possible should be set at “realistic levels”.

However, a full reading of the report revealed other key points of interest in terms of what the State obligations may be in terms of investigating the circumstances of the burials at Tuam.

It outlined five options which the Government could pursue when managing the location.

These range from doing no further investigative work to a full forensic excavation and analysis of all human remains.

It also revealed Ireland may be bound by law to investigate the deaths to the fullest degree possible.

“These include human rights issues around the right of an individual to a respectful and appropriate burial,” said the report.

“There is also the possibility that there may be an obligation under international human rights law, including under the European Convention on Human Rights, arising from the right to respect for family life. This could arguably entitle living family members to know the fate of their relatives.

“There is an obligation on the State, pursuant to the Irish Constitution (Bunreacht na hÉireann) and under human rights law, to fully investigate the deaths so as to vindicate the right to life of those concerned.”

As a result, Ms Zappone has asked Special Rapporteur on Child Protection, Dr Geoffrey Shannon, to examine these issues and to report to her on the matter.

If Mr Shannon finds that these rights exist, then it may influence which of the five options the Government chooses when dealing with the Tuam site, or indeed any of the other institutions where children are known to have died. His report is due next month.

In the meantime, we wait.

It would seem obvious that the fullest possible exhumation and analysis of the remains should be pursued. However, that would commit Government to the same course of action at every other potential site linked to a mother and baby home. This raises all manner of further issues — most notably cost.

In March, Catherine Corless hit out at the Government for focusing “on cost” rather than committing to a full forensic excavation, exhumation, and DNA testing of the remains at Tuam.

She expressed her anger at the “callous and cold voting system” put in place by Galway County Council as part of an independent consultation process on the five options presented by the ETG.

On forms issued by Galway County Council, interested parties were asked indicate their preferred option “by placing an X in the appropriate box” next to one of the five options.

Ms Corless’ intervention came just one month after the Irish Examiner uncovered evidence that children from the Bessborough Mother and Baby Home and another State-funded and accredited former adoption agency in Cork were buried in unmarked graves in a Cork City cemetery as late as 1990.

Tusla, who now hold the records, declined to say whether they had informed the Commission of these deaths before the Irish Examiner revealed them.

Both the Commission and the Department of Children and Youth Affairs have also declined to say whether or not all of the burials found would be investigated.

Whatever the Government decides to do with Tuam is just one part of the picture. The Commission will publish its final report in February of next year.

What it says on adoption will be crucial. It is too big a scandal to be simply tacked onto a report.

The children who died in these institutions can no longer speak for themselves.

However, there are thousands of adoptees out there — many of whom have no idea that there adoptions were illegal or that their identities were falsified. The scale of this scandal and the State’s role in this needs to be fully examined.

It will not simply go away.


Garda probe of baby deaths discrepancy in Bessborough sought

Campaigners have called for a Garda investigation into why the religious order which ran Bessborough Mother and Baby Home reported significantly higher numbers of infant deaths to state inspectors than it recorded privately.

An Irish Examiner investigation found between March 31, 1939, and December 5, 1944, Department of Local Government and public health inspector Alice Litster had been informed 353 infant deaths occurred at the Cork-based institution. The figures are contained in a inspection report from 1944 obtained by this newspaper.

However, the Bessborough Death Register revealed the nuns had recorded just 273 infant deaths in that period — a discrepancy of 80.

The discrepancy in the recording of deaths comes just months after this newspaper revealed an unpublished 2012 internal HSE report had raised concerns death records had been falsified in Bessborough Mother and Baby Home so children could “be brokered in clandestine adoption arrangements” at home and abroad.

Susan Lohan of the Adoption Rights Alliance said the gardaí now needed to become involved in order to ascertain why such a large discrepancy in the figures exists.

“We have been advised on numerous occasions by both the Minister for Children James Reilly and chairman of the Adoption Authority Geoffrey Shannon that if we believed there was evidence of wrongdoing to report it to the relevant authorities. It’s now time the gardaí investigate where these 80 infants are,” she said.

Ms Lohan said her organisation was regularly contacted by people who believe they were adopted from Ireland but when they contacted the Department of Foreign Affairs, they had been told they did not appear in the records relating to the export of babies to the US found in the National Archives in 1996.

Paul Redmond of the Coalition of Mother and Baby Homes Survivors has also called for a garda investigation into the issue of how deaths had been recorded at Bessborough.

“The Bessborough Death Register is another example of the Sacred Heart nuns’ complete disregard for the lives of babies and children in their care who died from neglect and indifference. The missing babies should be reported to the Garda and a full criminal investigation is necessary,” he said.

Independent senator and former Children’s Rights Alliance chief executive Jillian van Turnhout said she was “hugely concerned” at the discrepancies.

“If there is no register, as the order have said, then where are the other 80? We know that clandestine adoptions happened. It is reasonable to ask the question: ‘Is there a chance that there are people out there in their 70s that are adopted and do not know?’”

The Commission of Investigation into Mother and Baby Homes has said it will investigate the discrepancy in the figures.

The Sisters of the Sacred Hearts of Jesus and Mary said it was dealing directly with the commission on all such and related matters — and it “would not be appropriate to enter into communication, other than with the commission at this time”.

State feared public scandal over infant deaths at mother and baby homes

The State feared a “public scandal” in relation to the alarming number of children dying in mother and baby homes — 70 years before the Tuam babies scandal made worldwide headlines.

The revelation is contained in a letter sent on behalf of parliamentary secretary to the Minister for Local Government and Public Health Dr Con Ward in 1945 to the Bishop of Cork Daniel Cohalan.

The letter was in response to an angry letter sent to Dr Ward by Bishop Cohalan where he questioned the department’s request that the order remove the head of Bessborough over the “trouble” of infant mortality at the institution.

Records show there was an 82% infant death rate at Bessborough at the time.

“Rev Mother Martina has informed me that the Mother Superior in England was asked to remove her. That procedure was scarcely correct. Mother Martina is Reverend Mother of the Community of Sisters, it is an ecclesiastical appointment; it was not a correct thing to call for he removal,” he wrote.

However, in response, the department was clear that should information about the number of children dying leak into the public domain, it would result in a “public scandal”.

“The parliamentary secretary is only concerned with her position as matron of a home in which the death rate has reached an exceptionally high figure. The fact that 102 babies died in the institution before reaching the age of 12 months during the year 31st March last — the total infants born in the home and admitted after birth in that year being 124 — is viewed with disquietude.

“Apart from any public scandal which might result, the parliamentary secretary felt that the case called for immediate action and that to allow the Rev Mother Martina to continue as manager would mean acquiescence on his part in the state of affairs which has been disclosed,” stated the letter.

The 102 deaths referred to an 82% death rate at Bessborough reported to inspector Alice Litster for year ended 31 March 1944. Last week, the Irish Examiner revealed that this figure was substantially higher than the level of deaths the order recorded in its own death register.

Bishop Cohalan informs the department that he had spoken to the ex-chaplain at Bessborough and Sr Martina and that “the seriousness of the problem is realised”.

“The view is that a young doctor is needed, not a general practitioner but a specialist in gynaecology; that with a young doctor — gynaecologist — the cause of the mortality would be soon discovered and a remedy found,” he said.

The department agreed with this assessment but also expresses the hope that the re-organisation proposed by the superior-general of the order, whereby “an efficient and energetic Matron was to be transferred from Shan Ross to Bessboro, will have Your Lordship’s support”.

HSE fear of legal threat at Bessborough nuns’ past actions

The HSE expressed repeated concerns that the past actions of Bessborough adoption agency meant it had to be indemnified against any legal action taken by people seeking their records.

The concerns were raised throughout 2009 and 2010, in material released under Freedom of Information Act, as the Sisters of the Sacred Hearts of Jesus and Mary prepared to cease operating Bessborough as an adoption agency and transfer some 15,000-plus files to the HSE.

An undated memo of a meeting the HSE held with the management group from the religious order notes its desire to “manage liability for past Bessboro responsibility and ongoing re their activities as an adoption agency when and if it arises”.

In a letter on February 8, 2010, to solicitors representing the order, childcare manager in the HSE South region, Mike van Aswegen, said the HSE needed this assurance, as it had reason to believe that the past practices of the agency had “not always been exemplary”.

“In your correspondence, you refer to the need for providing an indemnity. I believe that in this case we will need to be provided with this comfort, as we have good reason to believe that the practice from the agency has in the past not always been exemplary,” he wrote.

Another memo from 2010 referenced legal advice that such indemnity would be required to protect the HSE: “Following legal advice to the HSE a further meeting took place on October 5, 2010. At this meeting matters concerning previous practice in the Society was discussed, and the issue of the Society indemnifying the HSE in the event that any claims would be made against the Society for past activity. The legal advice from the HSE solicitors had been that to safeguard the HSE this would be advisable.”

However, a non-dated service agreement briefing note, which appears to be from 2010, reveals that the order were initially not keen to indemnify the HSE.

“The Society stated they were not in a position to continue the arrangement of employing the staff nor were they prepared to indemnify the HSE should the HSE take over the files and the work involved in Search and Reunion,” read the memo.

An agreement was eventually reached with the order whereby it agreed to indemnify the HSE against “all liabilities, claims, charges, expenses, wrongdoing, losses or demands for an indefinite period”.

The order is also obliged to notify the HSE immediately when it becomes aware of any claim or potential claim being made against it.

In November of last year, an Irish Examiner investigation revealed the religious order which ran the Bessborough Mother and Baby Home reported significantly higher numbers of infant deaths to state inspectors than it recorded privately.

This came just months after another investigation revealed an unpublished 2012 internal HSE report raised concerns that death records were falsified in Bessborough Mother and Baby Home so children could “be brokered in clandestine adoption arrangements” at home and abroad.

In a statement, the order declined to comment on the HSE concerns about its past actions, stating it was dealing with the Commission of Investigation into Mother and Baby Homes “on all such and related matters” and that it would “not be appropriate to enter into communication, other than with the Commission at this time”.

Mother and Baby Homes: Revelations put State in uncomfortable position

The reaction of the Government to a shocking 2012 HSE report on Bessborough Mother and Baby Home has been instructive.

The revelations contained in the report have clearly put it in an uncomfortable position. Despite the shock displayed once the Tuam babies story went global — it is now clear that the Government had possession of a report showing a higher death rate in Bessborough almost two years earlier.

When the report, compiled as part of the HSE’s examination of the State’s role in the Magdalene Laundries as part of the McAleese inquiry, was made public by the Irish Examiner in June, along with equally disturbing material relating to Tuam Mother and Baby Home, the reaction of Government was to first deny it had ever seen it, then admit that, in fact, two departments had the report before finally labelling the entire study “conjecture”.

Even if you accept the “conjecture” line, it is impossible to get away from the finding on the number of infant deaths at Bessborough.

They are worth repeating. Between 1934 and 1953, Bessborough’s Registration of Deaths ledger records a “shocking” 478 children as having died at the institution.

To put this into context, this death rate is higher than that found by Catherine Corless in Tuam almost two years later – research which led directly to the State inquiry.

If the Government was so horrified by the death rate found in Tuam that it felt compelled to launch a State inquiry, then why was it not similarly moved in 2012?

When the Irish Examiner first revealed details of the HSE report, the Department of Children and Youth Affairs said it had no knowledge of the report. The department has since altered this position, stating that not only did it have a copy of the report, but so did the Department of Health. In a series of responses to parliamentary questions, children’s minister Dr James Reilly has sought to defend the lack of action on the deaths – which are described as “wholly epidemic”, “shocking” and a “cause for serious consternation” – by stating the 2012 report’s findings are “a matter of conjecture”.

It is important to put this “conjecture” line to bed. Firstly, the 2012 HSE report is based on an examination of Bessborough’s own records spanning from 1922 to 1982. These were transferred to the HSE by the order that ran the home — the Sisters of the Sacred Hearts of Jesus and Mary — in 2011. The 478 deaths recorded are taken directly from the order’s own death register. Based on the records, the author outlines a “narrative of patterns and practices of the Sacred Heart Order in the provision of adoption services at Bessboro”.

The records reveal an institution where women and babies were considered “little more than a commodity for trade amongst religious orders”, where “institutionalisation and human trafficking” took place among various religious orders and state-funded institutions and where women were provided with “little more than the basic care and provision afforded to that of any individual convicted of crimes against the State”.

The report is rock solid on the number of deaths listed, but says the question of whether or not all these children died but were instead “brokered” in clandestine adoption arrangements both at home and abroad was one which needed to be examined as part of a forensic investigation. It also says “further investigation is warranted” into the order’s accounting practices.

The records reveal clearly that the order requested payment from adoptive parents for the children they were adopting, while also requiring payment from the natural mothers for the care both they and their children received at the institution.

The author of the HSE report does state that the conclusions of the report were conjecture but, as always, context is everything.

The remark was in reference to establishing the interaction between the state, the order running Bessborough and the order operating the two Magdalene Laundries in Cork, and clearly indicates the Bessborough files reveal enough disturbing information to warrant a full forensic investigation.

“In order to conclusively verify interaction between the State and the Good Shepherd Sisters (who operated Magdalene Laundries in Sunday’s Well and Peacock Lane, Cork) and the Sacred Heart Order, it is imperative that full disclosure of any and all case files, records, institutional accounts and communications between the State and the religious orders be subject to forensic investigation. Until such time the conclusions of any such examination,” states the report.

None of the concerns raised in the Bessborough report are mentioned in the McAleese Report, nor does it appear any further investigation was done into the report’s findings.

The 2014 inter-departmental report on Mother and Baby Homes listed just 25 infant deaths at Bessborough, despite two Government departments being in possession of the order’s own figure of 478.

Dr Reilly has defended these omissions stating the findings were not “validated” and Mother and Baby Homes were outside the remit of the McAleese Committee. “As the issues raised in this draft report regarding death rates in Bessborough were outside the direct remit of the McAleese Committee, the HSE advised that these and other concerns would be examined separately by the HSE. At that time my department advised the HSE that any validated findings of concern from this separate process should be appropriately communicated by the HSE. My department is not aware of any subsequent report on this matter by the HSE,” he said.

This indicates that the department does not feel that a figure of 478 deaths taken directly from Bessborough’s Registration of Deaths transferred to the State by the order constitutes a “validated finding”.

While it is true that Mother and Baby Homes were outside the remit of the McAleese inquiry, that report points out that the committee uncovered material that was, “strictly speaking, outside its core remit” but chose to include it “in the public interest”.

This was because some of this material “may challenge some common perceptions” about Magdalene Laundries.

SPECIAL INVESTIGATION: Bessborough Mother and Baby Home: It’s time these women’s voices are finally heard

A previously unpublished report by the HSE in 2012 examined Bessborough’s own records. The in-depth findings and conclusions are damning. Conall Ó Fátharta reports

FOR years, places like Bessborough Mother and Baby Home were spoken of in hushed tones.

For generations of Irish people, they were places where thousands of women and girls were sent when they had “a problem”. They went in pregnant and came out alone, some after spending years locked away.

Some left only to be moved to other institutions and Magdalene laundries. Most were never the same. Their voices were never heard.


Over the years, those women have found their voices and have demanded answers for how they were treated behind the walls of Ireland’s mother and baby homes. Adoption rights campaigners have been doing the same.

Former residents and lay staff at the Bessborough home, run by the Sisters of the Sacred Hearts of Jesus and Mary, have spoken of an institution where women were denied pain relief in labour and basic medical care after birth, and were humiliated by having to cut the institution’s vast lawns on their hands and knees with a scissors.

Just last year, this newspaper uncovered that an official investigation carried out by the Cork County medical officer, on foot of inquiries from an inspector with the Department of Local Government, confirmed an infant mortality rate of 68% at Bessborough in 1943. The government briefly stopped sending women there as a result.

A previously unpublished 2012 HSE report on Bessborough, which examined the institution’s own records, show a system of “institutionalisation and human trafficking”, where “women and babies were considered little more than a commodity for trade amongst religious orders”, in an institution where women were provided with little more than the care and provision given to someone convicted of a crime against the State.

The report was prepared as part of the HSE’s examination of interventions by Irish State health authorities in the Magdalene laundries. It was based on an examination of Bessborough’s own records, which were handed over to the HSE in 2011.

Culture of greed

From the outset, the report, released under the Freedom of Information Act, is crystal clear in what the Bessborough archives reveal. It outlines an order preoccupied with materialism, wealth, and social status, where the women and children in their care were considered as a means to making money.

It points out that “a cultural snapshot” emerges of an era in Ireland where unmarried mothers were considered “not only as “fallen women” and violators of Roman Catholic moral order but were “considered little more than a commodity for trade amongst religious orders”

The report notes that, even though detailed financial records and accounts were not handed over to the HSE by the order, the archives still reveal that the order earned money from the women for the care of their children and also from the adoptive parents who took them.

“The only written confirmation of monies being paid were detailed within the ‘Catholic Women’s Aid Society Book 2, 1929-40’. Even a cursory glance at these pages reveals that monies were paid by natural mothers for the care of their babies, while adoptive parents were charged a sum ranging between £50-£60, payable on a monthly payment scheme in exchange for their adopted child. Further investigation into these practices is warranted,” the report states.

The admission books for the mother and baby home between 1922 and 1936 show the nuns “assigned account numbers to some women, (while not others) while marking some entries as ‘private’, ‘paid nothing’, or identifying which institutions or State bodies were financially responsible for the women’s upkeep“.

In other admission books, similar accounting practices were observed where women “were commonly assigned a ‘Reg No’, ‘Order Form No’, ‘Pink Form No’, ‘Admission Card’, ‘Admission Ticket’, or a notation of a ‘Card Received’.”

Minutes from meetings of the Sacred Heart Adoption Society’s board of management “further lend evidence to the order’s preoccupation with materialism, wealth, and social status” while the wealth and social status of the adoptive parents was often the prime concern when deciding whether they would receive a child.

“While an explicit criteria for adoption at Bessborough could not be located within any materials available during this research, it would appear from the board of management meeting minutes that prospective adoptive parents were assessed on the basis of their earnings, the size and condition of their home, and their social status within the community (not to mention the fundamental expectation that couples were practising Catholics), age, years married, and the committee’s ‘impression’ were mentioned most often as deciding factors [in] whether the couple would be ‘passed’ and ‘given a baby’ or not.”

The report lists a number of remarks at monthly meetings of the board of management between 1974 and 1982, stating that “one can formulate their own opinions about the relationships and interactions between Church and State and the judgements placed upon prospective adopters, and the attitudes toward the babies for whom they were entrusted”.

The entries include:

  • “Ages, 34 & 36, married 4-and-a-half years, Do not want a baby until Christmas.” (From the board of management minutes, April 9, 1979.)
  • “A very nice couple living in Limerick, their own hotel. The ages are 44 & 31; they have a very happy home and plenty of this world’s goods. Would like to adopt a baby. The committee passed them, and if babies are to spare they will get one.” (From the board of management minutes, June 13, 1977.)

Another entry from March 1977 reveals the “lax attitude of the Sacred Heart trustees toward child protection”: “Ages are 32 years… They are married 10 years and have a very comfortable home. They have all the necessary investigations… They are anxious to adopt a little girl. They have received a good reference from the priest but no Garda clearance.” This entry is then followed by the declaration “Passed”.

Shocking phenomenon of child deaths

The Bessborough files also raise questions about the “shocking” number of children who died in the institution. The report raises the question of whether death records were falsified so children “could be brokered into clandestine adoption arrangements, both foreign and domestic”.

It notes that, if this proves true, it could “have dire implications for the Church and State”, not to mention the families involved.

The HSE report reveals, for the first time, the exact number of children that were recorded as having died at Bessborough and states that the numbers unearthed “are a cause for serious consternation“.

“Though an examination of Sacred Heart’s Admission Register SHA/4 (1933-1953) accounts for 93 recorded infant deaths (not including those recorded as ‘stillborn’), a cross-reference with Bessborough’s Registration of Deaths ledger (1934-1953) unearthed a shocking phenomenon of infant mortality as 478 infant deaths were recorded for 19 years.”

That amounts to a death rate of 25 children a year. To put that in perspective, a total of 796 children are recorded as having died in Tuam Mother and Baby Home between 1925 and 1960 — a death rate of almost 23 children every year.

“As Bessborough’s death register contains less than two decades of details of Sacred Heart Adoption Society’s almost 75-year history, one cannot be certain as to the full scope of infant deaths. Curiously there are no death records for any years following 1953,” the report notes. However, the HSE does specifically raise the issue of what sort of conditions were present in the institution to allow such a “shocking” rate of infant death to occur.

“Returning to the matter of the death register, a phenomenal 478 documented infant deaths over 19 years leaves the reader asking what conditions precipitated the deaths of so many babies under the trust of the Sacred Heart Order.

“While a thorough inquiry is beyond the remit of this paper, one cannot help but ponder the implications of this phenomenon.”

In August of last year, this newspaper uncovered material in the Cork City and County archives which shows an official investigation into deaths in Bessborough carried out by the Cork County medical officer in 1943 confirmed an infant mortality rate of 68%.

The HSE report states that, in addition to revealing the number of babies that died between 1934 to 1953, the death record at Bessborough lists each child’s date of death, address, name, gender, age at last birthday, profession (marked as son or daughter), cause of death, and, in some cases, the duration of illness and the date when the death was registered.

The recorded causes of death in the entries include: Marasmus, gastro enteritis, congenital debility, spina bifida, congenital syphilis, pneumonia, bronchitis, congenital heart, tubercular peritiorities, cardiac shock, heat stroke, tonsillitis, and prematurity.

Inexplicably one entry which records a child dying of prematurity states that the child had turned three years of age at her last birthday.

Disturbing as these revelations are, perhaps the most shocking claim made in the HSE study is that death records may have been falsified for children so that they could be “brokered” for adoption, perhaps both at home and abroad.

“The question whether indeed all of these children actually died while in Bessborough or whether they were brokered into clandestine adoption arrangements, both foreign and domestic, has dire implications for the Church and State and not least for the children and families themselves,” the report states.

It notes that, while the subject of infant mortality may not appear to have much to do with adoption, the ‘boarding out’ of children with foster families, or the discharge strategies of women and children, its relevance becomes apparent “when put in context with the broader issue of the mutually beneficial State/religious order relationships and the covert relationships of the day”.

“Simply put the State had a social problem that it desperately needed to make go away, while the Church had the power and control to turn the ‘problem’ of illegitimacy into a lucrative money making enterprise,” the report states.

“While it is beyond the expertise of this author to proffer grand narratives about the historical, fiscal, or social arrangements forged between Church and State, the records themselves expose a telling indictment of what may have been one of Ireland’s most damning and destructive partnership of collusion, corruption, and abuse between Church and State.”

Institutionalisation and human trafficking

The archives paint an equally disturbing picture of how women were treated, with references to “institutionalisation and human trafficking”, “incarceration”, “confinement and servitude”, and to “a cold and lonely environment characterised by harrowing social, emotional, and physical isolation”.


The report points out that, while it is historically and socially acknowledged that little regard was given to the care of women pregnant out of wedlock in Ireland at that time, nonetheless “it appears that the women who sought refuge within Bessborough Adoption Society were provided with little more than the basic care and provision afforded to that of any individual convicted of crimes against the State”.

“While it is noted that entrants to Bessborough were not subject to the sanctions of any Irish court order, however their ‘voluntary’ admissions appear to have been a punitive reprise, far worse than a prison term,” states the report.

The report is also scathing about the “culture of confinement” which existed at Bessborough and a “practice of protracted detainment” where women and girls were kept in the institution long after their children were born and they should have been fit for discharge.

Analysis of admission records between 1922 and 1936 show that details for a “staggering” 43% of admissions had no recorded information regarding how they were referred to Bessborough. The second largest category of referrals reveals that 16% of admissions for this period were “By Ambulance”, while 15% came from family relations.

The HSE study notes that the figure of 43% could be interpreted as an administrative oversight save for the high level of specificity of details regarding a wide range of other referral mechanisms. For example, other referral mechanisms listed include:

  • GPs (11%);
  • Hospitals/Matrons (3.7%);
  • Nuns/Priests/Canons/Mother Superiors (2.7%);
  • County Homes (2.2%);
  • Cork Guardians (1.3%);
  • Other (1.2%);
  • Readmissions (1%);
  • Good Shepherd Sisters (0.5%);
  • Cork Union (0.5%);
  • Civic Patrol (0.1%);
  • Sr of Mercy (0.1%);
  • Sr of Charity (0.1%);
  • Bandon Guardians (0.1%);
  • Relieving Officer (0.4%);
  • Kilkenny CBH (0.4%);
  • England (0.3%).

Similarly, between 1933 and 1954, the sources of referral were unknown for 56% of 302 admissions.

Once admitted to Bessborough, the records examined by the HSE were found to “attest to the culture of confinement and servitude” and the “powerful air of authority that the nuns conveyed”.

“Society at large did not question the legitimacy of the Sacred Heart Order’s alleged powers of detainment; many of the women were kept there long past their delivery dates. It would appear that freedom to leave in one’s own time was beyond the reach of many women,” the report states.

Reference is made to one girl being sent to Bessborough in 1922 despite no record of her “being pregnant or ever having delivered a baby or what became of her after she entered the Good Shepherds”.

“What we can glean from this account is the prevailing morality of the times which sanctioned the incarceration of young females in an effort to prevent their moral degeneration. In this particular case mentioned, the young girl was accused of ‘being lead (sic) astray by a man’ so being locked up was considered justified.”

The HSE study states that Bessborough’s archives “reveal a trajectory of institutionalisation and human trafficking among various religious orders and State-funded institutions”.

However, the State is also singled out for harsh criticism for failing in its legal and ethical responsibility to ensure that the rights of unmarried mothers, particularly those under the age of majority, were safeguarded.“

Instead it would appear that the State turned their back on these women and girls, favouring instead to abdicate its responsibility to the religious orders.

“In exchange for assuming the State’s social and legal responsibility, the nuns benefited from a steady stream of free labour and servitude (not to mention financial remuneration for the women and their offspring).

“The practice of transferring women and children among and between State-funded religious institutions was prolific.”

Admission records

Indeed, the admission records of Bessborough reveal well-established practices of women and/or their babies being sent to “County Homes Unions, industrial schools, and orphanages, and within the network of convents and religious orders both domestically and within the United Kingdom” — in a practice that continued throughout the 1950s.

The report notes that the prevalence of such practices is witnessed by the scale of references within the admission registers “to women and children being bandied about from and within religious orders and institutions”.

The report outlines a snapshot of these practices of women and children being transferred among and between State and religious-run institutions as described in the Bessborough admission books between the 1920s and 1950s.

They include:

  • “Miss X age 22 sent to ‘Rev Mother St Mary’s School, North Hyde, Child placed in the school, March 1, 1926’”;
  • “Miss X age 21 Sent to Sanatorium, 18 , November 1927, Rtd (sic) 17.05.1928, Sent to Co Hospital, 05.09.1928’”;
  • “Miss X age 18 ‘Sent to Good Shepherd Convent, 7.06.1933’”;
  • “Miss X age 18 Mother & Child Dis (sic) to Co Home 07.07.1934 (Mental)”;
  • “Miss X age 18 having already spent three years in the care of the Good Shepherd Nuns in Co Kilkenny was admitted to Bessborough on the 12/11/25 (two years after the birth of her baby on 21/02/1923). This young woman was returned to the Good Shepherds on 12/02/1930”;

The report concludes by noting that the question regarding “the interconnectedness between Church and State demands a much more comprehensive exposition than has been offered here.

“The interdepartmental committee has a weighty task ahead of it as it seeks to ascertain the full scope of State/Church relationships, a formidable task by any standards.

“It is my hope that the material provided within this research paper is in some manner useful to the committee in making its conclusions.

“It goes without saying that the dignity and integrity of the women and children, both living and dead, who once lived behind Bessborough’s walls must be safeguarded and at long last their voices heard.”

In a statement, the Sisters of the Sacred Hearts of Jesus and Mary said it had “no knowledge of any such report”.

“We are in contact with the commission in regard to the mother and baby homes inquiry, which will be having our full co-operation. For the present, as is appropriate, we will be dealing directly with the commission on all related matters,” it said.

SPECIAL INVESTIGATION: Concern over possible falsification of Bessborough death records raised in 2012

Concerns that death records were falsified in Bessborough Mother and Baby Home so children could “be brokered in clandestine adoption arrangements” at home and abroad were raised in an internal HSE report in 2012.

The unpublished report highlighted the “wholly epidemic” infant deaths rates at the Cork home and said: “The question whether indeed all of these children actually died while in Bessboro or whether they were brokered into clandestine adoption arrangements, both foreign and domestic, has dire implications for the Church and State and not least for the children and families themselves.”

The report, compiled as part of the HSE’s examination of the State’s role in the Magdalene Laundries as part of the McAleese inquiry, lifts the lid on the culture of cruelty at the home and found the State effectively washed its hands of the women and children.

It reveals the institution, run by the Sisters of the Sacred Hearts of Jesus and Mary, as a place where:


  • Women and babies were considered “little more than a commodity for trade amongst religious orders”;
  • “Institutionalisation and human trafficking” took place among various religious orders and State-funded institutions;
  • Women were provided with “little more than the basic care and provision afforded to that of any individual convicted of crimes against the State”;
  • Infant death rates were “wholly epidemic” and a “cause for serious consternation”;
  • The order had a “preoccupation with materialism, wealth and social status”;
  • A “cold and lonely environment” prevailed, “characterised by harrowing social, emotional and physical isolation and institutionalisation”.

The study, previously released under freedom of information, revealed that from 1934 until 1953 (the only years for which deaths were recorded at Bessborough) 478 children died — a death rate of almost one infant a fortnight for nearly two decades.

The report said it was “curious” that there were no death records for any year following 1953 and, as a result, “one cannot be certain as to the full scope of infant deaths”.

However, in a disturbing revelation, the study raises concerns that the deaths of children may have been falsified so they could be “brokered” for adoption both at home and abroad.

“Simply put, the State had a social problem that it desperately needed to make go away, while the Church had the power and control to turn the ‘problem’ of illegitimacy into a lucrative money-making enterprise,” notes the report.

It notes that, even though detailed financial records and accounts were not given to the HSE by the order, the archives reveal the order earned money from the women for the care of their children and also from the adoptive parents who took them.

One record noted that, in the period from 1929 to 1940, “adoptive parents were charged a sum ranging between £50-60, payable on a monthly payment scheme in exchange for their adopted child”. The report said “further investigation into these practices is warranted”.

The Government did not launch an inquiry into mother and baby homes for almost another two years after the report was compiled in 2012.

In a statement, the Sisters of the Sacred Hearts of Jesus and Mary said it had “no knowledge of any such report”.

“We are in contact with the commission in regard to the Mother and Baby Homes Inquiry, which will be having our full co-operation. For the present, as is appropriate, we will be dealing directly with the commission on all related matters,” said the order.

The Department of Children and Youth Affairs said none of the concerns raised were brought to the attention of the then minister Frances Fitzgerald at the time, but were discussed in the context of McAleese Inquiry under the auspices of the Department of Justice.

It said the minister became involved in the issue of mother-and-baby homes once material around infant deaths in Tuam became public in mid-2014.

“The minister was subsequently tasked by Government with leading its response to these important matters and the Inter Departmental ReviewGroup was set up to assist deliberations on the terms of reference of a Commission of Investigation,” said a statement.

A request for comment from Tusla was not responded to at the time of going to print.