Mother and Baby Homes Commission of Investigation

Amateur historian Catherine Corless conducted research into babies born at the Bon Secours Mother and Baby Home in her hometown of Tuam, Galway. She collected data for several years, and published several articles in local newspapers in 2010, 2013, and 2014; her research suggested that the bodies of 796 babies and children may have been interred in an unrecorded mass grave at the Tuam Baby Home. Her research was brought to the attention of Alison O'Reilly, a reporter at the Irish Mail on Sunday. O'Reilly wrote an article on the subject in 2014, which garnered widespread international attention. Following the article, there were calls for an investigation of the site and for an inquiry into all such institutions. Bon Secours Mother and Baby Home The Commission was established by the Irish government in the aftermath of extensive worldwide media coverage of an investigation claiming that remains of up to 800 children had been interred in an unmarked mass grave, on the grounds of the Bon Secours Mother and Baby Home in Tuam, County Galway. The most commonly recorded causes of death among the infants were congenital debilities, infectious diseases and malnutrition. O'Reilly's article for the Irish Mail on Sunday said that the bodies were buried in a site at the Home and that there was a high death rate of its residents. Corless' research led her to conclude that that the site was also the location of a septic tank, when overlaid with maps of the period of use as a workhouse. Additional issues On 3 June 2015, the Irish Examiner published a special report which said that the Irish Health Services Executive (HSE) had voiced concerns in 2012 that up to 1,000 children may have been trafficked from the Home, and recommending that the then health minister be informed so that "a fully-fledged, fully resourced forensic investigation and State inquiry" could be launched. ==Establishment==

On 4 June 2014, the Irish government announced it was bringing together representatives from multiple government departments to investigate the deaths at the Bon Secours home and to propose how to address the issue. The Minister for Children and Youth Affairs, Charlie Flanagan, said any government inquiry would not be confined to the home in Tuam and that officials would advise the government on the best form of inquiry before the end of June 2014. On 16 July 2014, the government announced that Judge Yvonne Murphy would chair a Commission of Investigation into Mother and Baby homes, including Tuam. In October 2014, the Minister for Children and Youth Affairs, James Reilly, announced that the draft terms of reference for the inquiry had been circulated to government departments for comment. On 19 February 2015, Reilly announced that the terms of reference, agreed upon by the cabinet and signed by the as a Government Order at Tuesday's cabinet meeting, established an independent commission, which had a three-year deadline and a budget of approximately €21 million. The three-person Commission comprised Judge Yvonne Murphy as Chairperson, with an international legal expert on child protection and adoption, Dr William Duncan, and historian Professor Mary E. Daly, appointed as Commissioners. Terms of Reference The Terms of Reference specified for the Commission were to investigate and report on: The circumstances for the entry of single women into Mother and Baby Homes and the exit pathways on leaving, including the extent of their participation in relevant decisions; The living conditions and care arrangements experienced by residents during their period of accommodation, including by reference to the literature on the living conditions and care experienced by mothers and children generally during the period; Mortality among mothers and children residing in the institutions (to determine the general causes, circumstances, and rates of mortality), compared to mortality among women and children generally; Post-mortem practices and procedures in respect of children or mothers who died while resident, including the reporting of deaths, burial arrangements, and transfer of remains to educational institutions for the purpose of the anatomical examination; The extent of compliance with relevant regulatory and ethical standards of the time of systemic vaccine trials found by the Commission to have been conducted on children resident in one or more of the institutions (including, inter alia, vaccine trials conducted using vaccines manufactured by Burroughs Welcome in 1960/61, 1970 or 1973); Arrangements for the entry of children into the institutions in circumstances when their mother was not also resident at the time of their entry; For children who did not remain in the care of their parents, to examine exit pathways on leaving the institutions so as to establish patterns of the referral or relevant relationships with other entities, and in particular to identify: the extent to which the child's welfare and protection were considered in practices relating to their placement in Ireland or abroad; the extent of participation of mothers in relevant decisions, including the procedures that were in place to obtain consent from mothers in respect of adoption, and whether these procedures were adequate for the purpose of ensuring such consent was full, free and informed; and the practices and procedures for placement of children where there was cooperation with another person or persons in arranging this placement, including where an intermediary organisation arranged a subsequent placement; To identify the extent to which any group of residents may have systematically been treated differently on any grounds (religion, race, Traveller identity, or disability). The investigation covered the period from 1922, the foundation of the state, to 1998. Methodology In tandem with carrying out the investigations outlined in the Terms of Reference, the Commission was also empowered to establish a "Confidential Committee", with the aim of providing a forum for former residents and staff of the named institutions, where they could share accounts of their experiences. Such accounts were to be used to inform relevant investigations, and the Confidential Committee was to publish a report on the accounts received. The Commission also included a literature-based academic social history module, in order to establish an objective and comprehensive historical analysis of significant relevant matters. The Commission was authorised to rely on this analysis as evidence to inform its investigations and to assist it in framing its findings and conclusions within the wider social and historical context of the relevant period under investigation. ==Tuam excavation==

As part of its investigations, the Commission ordered excavations of the suspected burial site in Tuam to be carried out. On 3 March 2017, the Commission announced that multiple human remains had been found during excavations carried out between November 2016 and February 2017 at the site. Tests conducted on some of the remains indicated they had been aged between 35 foetal weeks and 2–3 years. The announcement confirmed that the deceased died during the period of time that the property was used by the Mother and Baby Home, not from an earlier period, as most of the bodies dated from the 1920s to the 1950s. The remains were found in an "underground structure divided into 20 chambers." The Commission said "it had not yet determined what the purpose of this structure was but it appeared to be a sewage tank. The commission had also not yet determined if it was ever used for this purpose." The Commission stated that it was continuing its investigation into who was responsible for the disposal of human remains in this way, and that it had notified the coroner. Reactions to excavation find In 2017 Minister for Children and Youth Affairs Katherine Zappone said that the coroner's results would determine the direction of the investigation and that the Commission would determine whether other sites needed to be excavated, including another part of the Tuam site. The Adoption Rights Alliance and Justice for Magdalenes Research campaign groups demanded that Zappone publish a five-month-old report from the Commission on the issue of broadening the probe's terms of reference beyond the original 18 institutions included, and said the state must ensure that all human remains buried in unmarked graves at institutions in Ireland are identified. (The report was published in April 2017; the delay, according to the Department of Children and Youth Affairs, was due to the report being referred to the Attorney General for advice on the report's recommendations on the issue of redress.) Speaking on the find in Dáil Éireann, in response to requests to widen the terms of reference of the Commission, he described the Mother and Baby Home as "a chamber of horrors." In the same debate, Bríd Smith, AAA-PBP TD, called for the Bon Secours order of nuns to be disbanded. She said, "its hospital empire, the biggest private hospital group in the State, was built on the bones of the dead Tuam babies". Smith said "everyone was not responsible for what happened in Tuam. It was paid for by the state, which knew exactly what was going on, and there were 'headage payments' of up to US$3,000 for each child sent to the United States." The Irish Catholic Bishops' Conference apologised for the hurt caused by its part in the system, which they said also involved adoptions. They also urged parishes to ensure that the burial sites of former residents were appropriately marked, and said that "the appalling story of life, death and adoptions related to the Mother and Baby Homes has shocked everyone in Ireland and beyond." Both TV3 and RTÉ broadcast documentaries on the scandal, with the latter's Claire Byrne Live including a segment listing the names of all 796 children who had died at the home. Catherine Corless appeared on The Late Late Show on 10 March 2017, receiving a standing ovation at the end of the segment. Host Ryan Tubridy said "If that audience represents the people watching tonight, there is a hunger in this country for the truth." Investigation team In June 2017, Minister Zappone announced the appointment of a team of international experts, comprising an Irish-based forensic archaeologist, a US-based forensic anthropologist and a UK-based forensic scientist, to investigate the burial site. Zappone also said that she was considering broadening the terms of reference for the Commission, in order to "help to answer some of the questions which have been raised again in public debate." The team is led by Dr. Niamh McCullagh, who previously worked with the Independent Commission for the Location of Victims' Remains in Northern Ireland and the Joint Prisoner of War/Missing in Action Command that aimed to locate the bodies of war dead. Zappone stated that McCullagh will identify options for the government, looking at the possibility of exhuming the remains and identifying if there are any further remains on the site that have yet to be discovered. The team is due to complete its final report in September 2017. In July 2017, the team conducted an extensive geophysical survey on the site. This consisted of data collection through a variety of non-invasive techniques, over the course of 5 days. The team liaised with the Coroner for North Galway, the Garda Síochána, the National Monuments Services and Forensic Science Ireland, and advice was received from the International Committee for the Red Cross. When Pope Francis visited Ireland in August 2018, Zappone raised the issue of the Tuam home in a meeting with him, and told him "I hope the Church will make reparation for its part in this shameful chapter," The operation would not be straightforward, and presented "unprecedented technical and legal issues". ==Criticisms during lifetime of the Commission==

The scope of the Investigation and in particular its restriction to just a limited number of named homes has been criticised by, among others, the United Nations Committee on the Elimination of Discrimination Against Women (CEDAW). In a 2017 report, it stated that the Commission of Investigation "is narrow such that it does not cover all homes and analogous institutions [and] therefore may not address the whole spectrum of abuses perpetrated against women and girls." ==Reports==

Commission reports The Commission was originally due to issue a final report by February 2018, but was given a one-year extension in December 2017. A second interim report was issued to the Minister in September 2016 and was published in April 2017. The delay, according to the Department of Children and Youth Affairs, was due to the report being referred to the Attorney General for advice on the report's recommendations on the issue of redress. A third interim report was published in December 2017. Commenting on the report and announcing the time extension for its final report, Minister Zappone said: The third interim report revealed that legal discovery orders relating to the records of Catholic religious congregations, which ran most of the homes, had been issued, but the Commission stated that "some have very little material available while others have provided extensive material". Government Departments, local authorities and the HSE were also issued with discovery orders. The issues raised in the Commission's third interim report included: • The time-consuming nature of investigations, in particular, establishing the burial practices at the Bon Secours Mother and Baby Home in Tuam, and the electronic scanning of records by Túsla, the Child and Family Agency; • What were described as "significant gaps" in the records of various health authorities with regard to institutions previously under their remit, necessitating further searches. This was exacerbated by sometimes multiple transfers of responsibility over the years, from local authorities/Board of Guardians/Boards of Public Assistance, to Health Boards, then to the HSE and, in some cases, to the Child and Family Agency. • Significant gaps in relation to the burial records of babies who dies in the institutions under investigation; • The Commission also stated that it had recorded testimony from 140 former residents, staff and representatives of those who had run the institutions, but more time was needed to gather and examine documentary evidence. In all, five interim reports were published. Departmental reports In July 2017, Minister Zappone announced that in addition to the Commission progressing its independent investigations, the Department of Children and Youth Affairs would separately report each month on the measures being progressed across Government to respond to the issues which have emerged so far from the work of the Commission. The second report was published on 4 August 2017. In total, these reports indicated that these homes housed 56,000 women, as young as 12 years old, and witnessed birth of some 57,000 babies; 15% of the mothers and/or babies died as a result of malnutrition or preventable illness. Surviving mothers were often separated from their babies, who were put up for adoption without maternal consent. Several of the homes were found to have conducted vaccination trials on the mothers and babies. Expert Technical Group report In December 2017, the Expert Technical Group reported to the Department of Children and Youth Affairs, outlining five possible courses of action on the Tuam site. These are: • "Memorialisation: No further investigative work; return the site to being managed as a memorial; make site safe for public access." • "Exhume known human remains: Recover human remains interred in the chambered structure identified to date and reinter elsewhere; no further forensic analysis of remains." • "Forensic excavation and recovery of known human remains: Complete forensic archaeological excavation, recovery and analysis of human remains from the chambers identified to date." • "Forensic excavation and recovery, and further evaluation/ excavation of other areas of potential burial/ interest: Complete forensic excavation and recovery of all human remains in memorial garden and any other targeted area, following geophysical survey, assessment of witness statements, historical records, etc." • "Forensic excavation of total available area: Full forensic and archaeological excavation of all available ground formerly occupied by the M&B Home. A total of 0.4 hectares, comprising memorial garden, playground, car park etc. Excludes private built areas (houses and gardens etc. subsequently built on the former site)." Zappone said that before any decision was taken, she first wanted to consult with the Tuam community and other affected parties, such as relatives of those who were resident in the home. She said the consultation process, which would be undertaken by Galway County Council, would take three months. A report was published in April 2018, by Galway County Council based on qualitative and quantitative research conducted by Barbara Walshe and Catherine O'Connell. The Tuam Home Survivors Network said its members had given careful consideration to the Expert Technical Group's report and that the only appropriate action was "a complete excavation of the Tuam site to ensure the recovery of all human remains contained there." The Network were also seeking a postmortem for each set of human remains and cataloguing of DNA from all remains in order to create the most complete database possible. The report recommended the establishment of a voluntary scheme to collect DNA from survivors and relatives of Tuam, with their informed consent, in order to match DNA to be collected from the remains of the dead. The voluntary scheme would be run on an administrative basis, with no DNA profiling to occur until legislation was in place to underpin the excavation and exhumation of remains and permit their DNA testing, where this proved to be possible. The final report is some 3,000 pages in length, including 1,000 pages of survivor testimony and an 'executive summary' of 200 pages. It was due to be given to survivors prior to publication, but was leaked to the Irish Independent newspaper on the weekend before, which drew strong criticism from the Minister involved, Roderic O'Gorman. Findings of final report Deaths The report detailed an "appalling level of infant mortality at mother-and-baby homes," and said "in the years before 1960 mother-and-baby homes did not save the lives of 'illegitimate' children; in fact, they appear to have significantly reduced their prospects of survival." It detailed that around 9,000 children, one in seven of those born in the 18 institutions covered by the Commission's terms of reference, had died in them between 1922 and 1998, double the rate of infant mortality in the general population. The trials detailed in the report include: • 1930 Trial of Wellcome anti-diphtheria vaccine on 142 children in two unidentified orphanages and to 436 children aged between eight months and 14 years among the general child population in Cork city. • 1934 Trial of Wellcome anti-diphtheria vaccine on 24 children, varying in age from seven months to 14 years, resident in the Dublin Union, later known as St Pat's. • 1934–1936 Trial of Wellcome 'one-shot' anti-diphtheria vaccine to 250 children in an unidentified residential institution for boys and to 2,541 children among the general population in County Cork. • 1935 Trial of Wellcome vaccine on 46 children, aged four to 15 years, resident in St Vincent's Industrial School, Goldenbridge, St Joseph's School for Deaf Boys, Cabra, and St Saviour's Orphanage, Lower Dominick Street, Dublin. • 1935 Trial of Wellcome anti-diphtheria vaccine in children's residential institutions in Tipperary, likely the three industrial schools in Tipperary South: St Bernard's Industrial School, Fethard; St Francis's Industrial School, Cashel; and St Joseph's Industrial School, Ferryhouse, Clonmel. • 1960–1961 Trial of Wellcome Quadruple (4 in 1) vaccine "Quadrivax" on 58 infants and children resident in a number of institutions, including Bessborough, St Patrick's Home, Navan Road; Dunboyne; Castlepollard; St Clare's Home, Stamullen and Mount Carmel Industrial School, Moate. • 1964 Trial of Wellcome "Wellcovax" measles vaccine on 12 children living in Sean Ross. • 1964–1965 Trial of Glaxo Laboratories "Mevilin-L" measles vaccine on children living in Bessborough and St Patrick's, Navan Road. • 1965 Trial of Glaxo Laboratories Quintuple (5 in 1) vaccine on children Bessborough and St Patrick's, Navan Road. • 1968–1969 Trial of Glaxo Laboratories 'Mevilin-L' measles vaccine on at least 30 children resident in St Patrick's, Navan Road. • 1968–1969 Trials of experimental replacement formula milk took place in St Patrick's Navan Road), and Bessborough. • 1970 Trial of Wellcome's Rubella vaccine on 72 children living in the general community and 69 children aged between two and 18 years old "resident in an orphanage in a suburb of Dublin". • 1973 Trial of Wellcome's modified DTP vaccine on 65 children in the general community and 53 children resident in St Patrick's, Navan Road, and in three residential children's homes. The Commission found that the trials in seven institutions it investigated were "illegal and unethical even by the standards of the time", that trials had proceeded without being licensed, that regulatory standards had not been upheld. The report states that the trials would have been a basic breach of the Nuremberg Code, and that no consents had been obtained for children in institutions. A spokesperson for AMRI, Conrad Bryan, said:On the one hand to say there was no evidence of discrimination and then to continue on and say race was taken into account in placing children—that's a very confused inconclusive statement. It just appears that the testimony we've given has basically not been believed. They relied primarily on records they discovered and checked. However, a lot of the testimony can be seen in the report and people can read and make their own judgements on it and see the extent of the racism. The commission says itself there was casual and unthinking racism, even negative bias, so they're clearly showing that racism existed. I was in Pelletstown during the 1960s and the report says virtually 100% of illegitimate children were adopted. Of the majority of the mixed-race children in Pelletstown, only 48% were adopted. Now if that isn't racism, can somebody explain to me what is racism? ==Reactions to Commission's final report==

The release of the final report generated huge media interest, in Ireland and abroad. The state broadcaster, RTÉ, published over 40 news articles on the topic in the days following release. Criticism of church and state Taoiseach Micheál Martin, in his formal state apology, described Ireland’s historic treatment of unmarried mothers as a "profound generational wrong". He spoke of a "warped attitude to sexuality and intimacy", where piety was honoured, yet basic kindness was denied. He admitted that young mothers and their children had paid a "terrible price" for societal dysfunction. The Taoiseach also promised that the apology would be followed by actions, including access to counselling and records, provision of medical cards, and a system of reparations. Survivors and their advocates were also critical. The Tuam Survivors Network pushed back on the notion that society as a whole was to blame, arguing that both the State and Church were institutions run by men who lacked compassion. The Coalition of Mother and Baby Home Survivors went further, describing the treatment of mothers and children as "downright criminal." They cited forced labour, abuse, and medical neglect, calling the abuses clear breaches of human rights, asserting that "women were made to scrub floors and stairs and treated as slave labour and were also treated appallingly while in childbirth by denial of doctors, medical equipment and painkilling drugs." Criticism of the Commission's conclusions Significant criticism was directed at how the Commission interpreted survivor testimony and framed its conclusions, with of Catherine Connolly describing the report's conclusions as "extraordinary" and disconnected from the lived experience of those who came forward. She pointed to the Commission's claim that there was no evidence of women being forced into the homes - a conclusion she found incomprehensible, given the stories shared. She also noted the report's failure to adequately acknowledge sexual abuse, rape, and forced adoption, saying that this was contradicted by witness testimony. Roderic O'Gorman, the Minister for Children, Equality, Disability, Integration and Youth and the official to whom the report was presented similarly questioned the Commission's approach, particularly what he called its narrow, legalistic view of consent. He argued that in many cases, women had been left with "absolutely no choice." He declined to endorse how the Commission had conducted its inquiries. O'Gorman committed to a GDPR-compliant approach to new adoption information and tracing legislation, which he promised would be enacted by the end of 2021, and to the establishment of a redress scheme. The project was stated in August 2022 to have been abandoned. Catherine Corless, whose work led to the setting up of the Commission, said that she was disappointed with aspects of the report, saying it was "vague" about illegal adoption. She said survivors were still waiting for meaningful acknowledgment from the institutions responsible. She called for actions to back up the state apology. Multiple advocacy groups described the report as incomplete. The Irish First Mothers Group accused the inquiry of absolving Church and State of systemic responsibility. The Commission was criticised by survivors and Oireachtas members for twice refusing to appear before the Oireachtas Children's Committee in order to give a briefing and answer questions on the final report. This criticism was revisited and repeated in June 2021, when it emerged that members of the Commission were presenting at an academic seminar in Oxford University, on the work of the Commission. The Tánaiste, Leo Varadkar, describing it as "disrespectful." Many survivors criticised the report, in particular for concluding that there was a lack of evidence of forced adoption and abuse, despite testimonies contradicting this, and it was confirmed that the Investigative Committee was given more weight than testimony presented to the Confidential Committee. Some survivors said that their testimonies were amended or misrepresented. Later in June, the former Commission members again refused to appear before the Children's Committee, provoking further criticism from survivors and committee members. Some survivors and members of Oireachtas called on the Minister to repudiate the report. Catherine Corless described the Commission's response "an eye-opener" and said the process of gathering and recording witness testimony had turned out to be a "complete waste of survivors' time." Their statement admitted to the disrespectful burial of children on the premises but pledged participation in a forthcoming restorative recognition scheme. The Sisters of the Sacred Hearts of Jesus and Mary ran Bessborough House in Cork. This institution had a particularly high infant mortality rate and current controversy surrounds the location of burials of children on the grounds and the order's plans to have the lands developed. The order apologised for the particularly high infant mortality at their institution and expressed sorrow over the lack of clarity surrounding the burial locations of many children. They stated that they had worked with a professional historian to help the Commission investigate this issue, though they acknowledged the difficulty in achieving legal certainty. ==Aftermath of the final report==

Restorative recognition and action plan In the aftermath of the publication of the Commission's final report, in November 2021, the government announced that it was to introduce a series of measures to address the issues raised and the resulting calls for justice. These included: • The enactment of legislation to allow the release of birth information to adopted people; this became the Birth Information and Tracing Act, 2022. • The establishment of a "National Centre for Research and Remembrance", to be built on the grounds of a former Magdalene Laundry in Sean McDermott Street, Dublin. • Restorative recognition, in the form of: • access to counselling and medical services, and • a payment scheme, to offer compensation to those who had been in Mother and Baby Homes. The Irish Council for Civil Liberties claimed that over 40% of survivors would be excluded. Criticisms Following publication of the final report, survivors sought access to their own records by making Subject Access Requests (SARs) to the Department of Health. This resulted in forms used by the Commission to compile their report from witness testimony being shown to be unfit for purpose, according to survivors and their families. The daughter of one survivor said that it was "incomprehensible that options such as rape, incest, extra-marital and casual encounter are included under 'current relationship status' without anyone saying this is an issue. Also, it shows they never expected this to get into the public domain. In what world is rape or incest a relationship status?" Some of those who received access to their records claim that material on their file was forged. For example, one survivor was given a letter from her file, in June 2021, that was purportedly written by her, thanking Ard Mhuire Mother and Baby Home for their help. She denies ever writing such a letter, and points out phrasing in the letter she would never have used. In July 2021, it was announced that two test judicial review cases were being taken by Mother and Baby Home survivors Philomena Lee and Mary Harney. Their cases seek to quash elements of the Commission's final report, with Lee's court submission stating "numerous findings of the Commission in its final report which are at odds with the testimony of [Lee] provided on affidavit to the Commission." The Commission did not provide Lee with a draft or extract, as required by section 34 of the Commissions of Investigation Act 2004. A third case taken by Mari Steed sought to quash that part of the Commission's finding that there was no evidence any child was harmed by vaccine trials carried out at the institutions. The cases were heard in late 2021. On 17 December 2021, the High Court issued its judgement, declaring that the Commission of Investigation had treated survivors unlawfully. Alternative report In the aftermath of the publication of the Commission's final report, ongoing media commentary focused on the discrepancies between the findings in the report's executive summary and actual witness testimony that directly contradicts those findings. The discrepancies led to calls for the report to be repudiated by the government. One such call was made by Caitríona Crowe, former head of special projects at the National Archives of Ireland, who said "[The report's] conclusions are disputed, not just by survivors, but by many commentators who do not share the commission's view that Church and State were not the primary movers and operators of this vast system of incarceration and family separation. The repudiation of these findings would not be seen by most as a loss; on the contrary, many survivors view their rejection, as the State's official view of what happened to them, to be essential." In July 2021, a group of 25 researchers and academics announced that over the months since the publication of the original report, they had established a project to explore whether the Commission could have come to different findings, using the evidence available to it. They concluded that the Commission had sufficient evidence before it to find multiple abuses of key human rights provisions. Their "alternative report" was published on 15 July 2021. ==See also==