“The death of a loved one is probably the most difficult event any of us will experience in our lifetime,” wrote Deirdre Madden.
“When the death is that of a child, the trauma and grief is immeasurably increased, whether or not death was expected.
“The death of a child is inherently against the natural order of life where the oldest die first and it can cause lifelong heartbreak.”
The subject matter of the inquiry was a heart-achingly sad one, touching our deepest instincts.
And reading through the 140 pages of the report, you were left in little doubt about how conscious Dr Madden was of the fallout from a paternalistic culture and legal vacuum that allowed doctors to retain organs and glands from the bodies of dead children without bothering to obtain the consent of parents.
“Parents did not know that their child’s brain could be removed and fixed for a period of time prior to examination and that other organs, principally hearts and lungs, were removed and retained for examination ... or that after examination, that organs would be incinerated with other hospital waste,” she wrote.
The report quotes one parent who said: “The general attitude and demeanour of the medical profession in general ... was condescending bordering on arrogance and that ‘we know best’ and ‘you do not have to know anything about this’.”
The report is an imperfect one but was still some achievement, given the sorry saga that had preceded it. The original Dunne Inquiry was terminated after five years, having amassed costs of many millions of euro, having lost the support of Parents for Justice - the group representing bereaved parents - and having produced a 3,500 page report that remained unpublished on the advice of the Attorney General.
Dr Madden was drafted in by Mary Harney in a Red Adair role, essentially to salvage the inquiry. In the span of eight months given to her, she produced her report. Yes, it was imperfect. Its terms were severely circumscribed, excluding, for example, organ retention relating to still-born children and to those children over the age of 12.
It heard no new evidence and was based largely on a reading of the material that had already been collected by the Dunne Inquiry.
The findings were general rather than specific - there was no individual attribution of blame; no singling out of hospitals, doctors or officials.
Parents for Justice described the report as “fundamentally flawed”, pointing out that it failed to arrive at a figure for the number of pituitary glands sold to two pharmaceutical companies in the 1970s and 1980s.
Dr Madden ascribed the failure to seek consent to the paternalistic culture that held sway in the medical profession during the 1970s and 1980s.
She also identified the complete vacuum of legislation governing hospital post-mortems; the absence of any policies or guidelines within the Department of Health; the fact that nobody within Health raised any red flags about the practice or about glands being sold.
It was only when the first case was reported in Ireland in 1999 when the giant finally awoke from its long sleep.
Yes, some would say she pulled her punches somewhat. While attributing the failures to the paternalistic culture of the medical profession, she goes on to say that “fairness demands that the conduct of doctors be judged by the standards of the time, not by the ethical principles that are now expected as standard practice”.
Having said that, the report concisely and sensitively identifies the culture that led to these practices, gets to the heart of why it was so, and describes how and why it caused such terrible trauma and grief to unsuspecting parents years afterwards.
All inquiries held after the event (sometimes many years later) are imperfect. Only one in recent memory - the very limited McCracken enquiry into payments by Ben Dunne to Michael Lowry and Charles Haughey - met with almost universal approval.
Madden’s inquiry lasted eight months and cost a tiny fraction of the Dunne Inquiry (though in fairness, it drew heavily on its work).
But it does show that private inquiries run by experts (as opposed to lawyers) can be a far more effective vehicle to investigate matters of public controversy than the unwieldy, lumbering, procedure-laden and grotesquely expensive Tribunals of Inquiry.