Thousands of children died in Ireland's Mother and Baby Homes with no concern from the State or society, the Commission of Investigation has found.
- 56,000 women were incarcerated, 5,616 of them under 18. Some were as young as 12
- Approximately 9,000 of the 57,000 babies born in these homes died
- Ireland had the world's highest proportion of women sent to mother & baby homes in the 20th century
- In the 1930s and 1940s, 40% of babies in the institutions died before their first birthdays
- 75% of the children born in Bessborough in 1943 died in their first year. In that same year, 62% of babies born in the Bethany Home died
- From 1946-55 mother and baby homes accounted for 39.6% of deaths of 'illegitimate' children
- No findings of widespread physical abuse despite a number of testimonies of beatings and brutality
- Childbirth was traumatic with poor medical assistance
- Recommends a referendum to change the law to allow adoptees find their families
Around 56,000 unmarried mothers, some as young as 12, passed through, and 57,000 children were born, in the mother and baby homes under investigation by the Commission - with the highest admissions in the 1960s and early 1970s.
"It is likely" there were a further 25,000 unmarried mothers and more children in the county homes which were not investigated.
The 3,000-page final report is a result of the judicial commission of investigation established in 2015 to investigate claims of the improper burial of infants, illegal adoption and cruelty to the women kept in the institutions and includes 1,000 pages of survivor testimony.
The women in the homes were aged from just 12 years old to women in their 40s.
One in 10 of the women institutionalised, (5,616) was under the age of 18, while 80% were between 18-29 years old.
Pelletstown (Saint Patrick's Mother and Baby home on Dublin's Navan Road), followed by Bessborough (Cork) accounted for the largest numbers of women under 18, Dunboyne (Meath) had the highest proportion, with almost one in four women there underage - 23.4%.
"While mother and baby homes were not a peculiarly Irish phenomenon. the proportion of unwed mothers who were admitted to homes in the 20th-century was probably the highest in the world," the report found.
"There is no evidence that women were forced to enter the mother and baby homes by the church or state authorities. Most women had no alternative. Many pregnant single women contacted the Department of Local Government and Public Health, their local authority or a Catholic charity seeking assistance because they had nowhere to go or no money."
The report also found women were brought to the mother and baby homes by their parents or other family members without being consulted as to their destination.
The report found that the vast majority of children in the institutions were "illegitimate" and because of this suffered discrimination for most of their lives.
The vast majority have no memory of being there, however, some stayed in the institutions until the age of seven.
"The very high rate of infant mortality (first year of life) in Irish mother and baby homes is probably the most disquieting feature of these institutions. The death rate among 'illegitimate' children was always considerably higher than that among 'legitimate' children. A total of about 9,000 children died in the institutions under investigation - a fraction of all the institutions that operated in the country.
"The very high mortality rates were known to local and national authorities at the time and were recorded in official publications," the report states.
The major identifiable causes of death were respiratory infections and gastroenteritis but "there is no single explanation for the appalling level of infant mortality".
"There is little evidence that politicians or the public were concerned about these children. No publicity was given to the fact that in some years during the 1930s and 1940s over 40% of 'illegitimate' children were dying before their first birthday in the home.
"The Bethany management board could describe health in the home as 'excellent' despite the minutes of the same meeting recording the deaths of a number of children."
"In spite of serious further efforts the commission has not been able to establish where the majority of the Bessborough children are buried," the report adds.
"A number failed to keep any records of the burials of children who died.
"The commission finds it very hard to believe that there is no one in that congregation who does not have some knowledge of the burials of the children. Similarly, the Commission considers that there must be people in Tuam who know more about burials there."
"The Commission finds it very difficult to understand the seeming inability of any member of the Congregation of the Sacred Hearts of Jesus and Mary to assist in locating the burial places of children who died in Bessborough."
Despite the fact that thousands of babies died, the commission is aware of only a few mothers who were not in the institutions when the child died, who subsequently sought information on the burial location of their children. At least one was given incorrect information - "This is unforgivable," the report states.
Children resident in the homes describe being punished for minor infractions by nuns and were kept at the back of the class when attending school.
Statements detail being dragged from bed by their ears, which in one case has resulted in a loss of hearing in later life, and beaten if they had wet the bed.
Another stated his hand was placed in boiling water for "being bold".
One man stated his mother told him she was evicted from the institution after she attacked a nun.
Another stated that after being deprived of water while suffering from chicken pox, he drank from a toilet.
Others state they were bathed in boiling water with Jeyes Fluid which burned their skin.
The report identifies 13 vaccine trials which took place in the institutions between 1922-1998, seven of these were conducted in the institutions covered by the Commission from 1934-1973 and identified a further suspected trial in 1965 in Pelletstown but has not yet been confirmed.
Pharma-giant GlaxoSmith Kline provided extensive documentation about trials conducted in children's institutions from 1930-1973.
A number of children involved have been identified.
"It is clear that there was not compliance with the relevant regulatory and ethical standard of the time as consent was not obtained from either the mothers of the children or their guardians and the necessary licenses were not in place.
"Who the guardian is, however, is largely irrelevant as no attempt seems to have been made to seek the consent of parents or guardians.
"There is no evidence of injury to the children involved as a result of the vaccines," the report found.
The report states that "before the availability of legal adoption (from 1953) children who left the institutions usually ended up in other institutions such as industrial schools or were boarded or nursed out. After legal adoption became available it gradually became the most likely outcome."
The Commission says they have received evidence from some mothers who say their consent was not full, free and informed. Many state that they were only taken in by the homes on the condition that they would have their child adopted.
"An adoption order could not be made without the consent of the child's mother or guardian," the report said.
"A mother was required to sign two distinct contracts: an agreement to place the child for adoption and a second consent to the adoption order.
"A mother could withdraw her consent at any stage up to the making of the adoption order, though a number of legal cases suggest mothers were not always aware of this."
The commission found that 1,638 children who were resident in the homes were placed for foreign adoption. The vast majority in America.
- One-third of the children with intellectual disabilities in Pelletstown were the children of married couples.
- In cases where the mother was perceived be "mentally handicapped," the children were assessed on the basis that they too could be "backward" and may not be "suitable" for adoption.
- Many women who were considered "mentally defective" were still considered fit to consent to have their children adopted.
- There are instances in the report of children being fostered and then returned to the institutions when the new parents found the child had Down syndrome or another intellectual disability.
- Those considered "developmentally slow" were labelled "not fit for adoption".
- One assessment in 1968 states: "This little mongol cannot sit, stand or speak."
"Archbishop McQuaid and Fr Cecil Barrett, who strictly speaking had no right to be involved at all, were actively involved in trying to control foreign adoptions and did manage to have some standards applied," the report states.
Many allegations have been made that large sums of money were given to the institutions and agencies in Ireland to arrange foreign adoptions, however, the commission states: "Such allegations are impossible to prove and impossible to disprove."
The Commission found that in Bessborough and Pelletstown, there was no evidence of discrimination in relation to decisions made about the adoption of mixed race or children with disabilities. However, discrimination did play a major role in which children were adopted.
Kilrush (Clare) and Tuam (Galway) homes had "appalling physical conditions". Kilrush had no electricity, running water or sanitary facilities. Tuam was "not dissimilar". Despite holding over 200 children, Tuam "was lacking the most basic sanitary facilities". Children's rooms were devoid of toys and were heated by open fires.
Women state they were forced to wear underwear for two or three days before given a new, clean pair, and sanitary products were rare and made of towel.
Work began at 7am after mass and breakfast at 5am.
"The women worked but were generally doing the sort of work that they would have done at home; women in the county homes did arduous work for which they should have been paid," the report states.
There are reports of women in Castlepollard and Sean Ross cutting timber.
"The women and children should not have been in the institutions," the report states, but goes on to state there is "no evidence of the sort of gross abuse that occurred in industrial schools. There are a small number of complaints of physical abuse."
The report states that: "There is very little evidence of physical and no evidence of sexual abuse," but goes on to document the sworn affidavits from women who detail being beaten and tortured.
Resident F (14) was pregnant and taken to Castlepollard: "I was beaten by the nuns with a stick.
"You got beaten by sticks or by their hands, across your face, your head, arms, legs or torso."
She said that nuns made her unblock toilets with her bare hands, which would make her physically sick.
After her difficult birth, she was made to come back to the home even though she could not walk on her own.
Resident (A) was raped by her boyfriend and became pregnant at 18, she told the commission she saw "about ten" deceased babies being sent for burial in what appeared to be shoeboxes.
Resident (B) told the Commission her baby was delivered by a girl with Down syndrome with no nun in attendance.
Resident (H) became pregnant at 20 as a result of rape. When she visited the parish priest to tell her story, she says the priest then sexually assaulted her in his car. The medical officer at Castlepollard examined her once a week: "I hated him; He was so rough, he used to examine me internally from the back passage and I was sore for ages after."
She was stitched without any anaesthetic. "I later found out that he had cut right through my rectum and I had six stitches. I couldn't go to the toilet properly for years after that." She said she was unable to walk after her labour as "they had damaged a nerve in my right leg".
This resident says she was physically attacked by a nun who told her that all she was "good for was lying under men".
One woman documented being forced to scrub a floor shortly after labour, when her stitches burst, she was forced to clean up her own blood.
Many of the women did suffer emotional abuse and were often the subject to degradation and derogatory remarks and "it appears there was little kindness shown to them and this was particularly the case when giving birth".
The atmosphere was cold and "seemingly" uncaring. They offered little sympathy or counselling to women. Women were dissuaded from sharing their stories with fellow residents "because of concerns to protect their privacy".
Many women found childbirth to be a traumatic experience. The overwhelming majority were first-time mothers and probably uninformed about childbirth.
"Women transferred to maternity hospitals to give birth were subject to unfriendly comments from fellow patients and visitors," the report adds.
In county homes, the conditions were very poor for all residents including older people and people with disabilities.
"The women in county homes have been largely forgotten" many women on a second pregnancy or the poorest families, mental health, special needs, venereal disease or a criminal conviction who were rejected from mother and baby homes were kept here.
They also accommodated children with special needs from married families, "the accommodation and care given to these children was grossly inadequate, some of the descriptions are extremely distressing," the report states.
The report found that local authorities deferred to the views of the religious orders. Galway County Council acceded to the demands of the Bon Secours that children should remain in the Children homes until five for boys and seven for girls, despite the fact it contravened government policy.
When Mayo County Council threatened to remove children, the Sisters threatened not to admit Mayo children, and eventually, the local authority backed down.
"There is no evidence that the Catholic hierarchy played a role in the day-to-day running of the mother and baby homes," the report states.
"The Commission has not seen any evidence that the religious orders who ran the mother and baby homes made a profit from so doing. At various times it is clear they struggled to make ends meet... when occupancy levels fell and women stayed for short periods."
The Commission acknowledges that many former residents are critical of the tracing and information arrangements in place, and that criticism of Tusla is "unfair and misplaced".
"The problem is not with Tusla, it is with the law," the report states.
Adopted people do not have a right to access their original birth certificate nor do they have the right to access information on their families of origin.
"Information is limited in most cases, however, the commission considers that there should be such a right even though it is acutely conscious of the concerns expressed by some birth mothers about this.
"If, as seems likely, a referendum is required to allow for the necessary legislation, then one should be held."