Despite very extensive inquiries and searches, the Commission has been able to establish the burial place of only 64 children. The Congregation of the Sacred Hearts of Jesus and Mary who owned and ran Bessborough do not know where the other children are buried.

The Commission said it found this "very difficult to comprehend" and said that the affidavit on burial practices supplied by the Order "was, in many respects, speculative, inaccurate and misleading".

The Commission carried out a site survey of Bessborough and said that, while it was clear there are a number of locations within the grounds where burials could have taken place, "there is no significant surface evidence of systematic burial anywhere except for the congregation [nuns] burial ground" on the property.

Late last month, the Commission confirmed it had carried out a geophysical survey on the grounds of the Sean Ross Abbey on foot of information received from a member of the public.

It was the first time that any potential infant burial site outside of Tuam has been examined and comes more than three years after the first geophysical survey of the Tuam site.

With the focus widening, the spotlight has now turned to Bessborough Mother and Baby Home – the second largest institution of its type. To date, it has the highest infant mortality rate recorded at any Mother and Baby Home – 82% in 1944.

However, the Commission is charged with examining a range of issues in relation to the institutions it is examining - not just infant mortality and burial practices. It is also looking living conditions and care arrangements at the institutions, vaccine trials and adoption practices including whether or not the consent of mothers was full, free and informed.

What is likely to find in relation to Bessborough?

Over much of the past decade, this newspaper had uncovered a vast amount of detail on all of these practices. It is expected that the Commission will reveal even more given its access to the records.

INFANT DEATHS

The research of Catherine Corless with regard to the 796 children who died in the Tuam Mother and Baby Home was the catalyst for a State inquiry into all of these matters.

When it became news that flashed around the world in 2014, the State was left with little option but to announce an inquiry.

However, two years earlier, a call for an inquiry had also been made by senior management within the HSE.

At that time, the McAleese Committee, which was examining the Magdalene Laundries, had requested records relating to the 10 institutions under its remit be examined by the HSE.

Permission was granted to include two mother and baby homes in this trawl — Bessborough in Cork and Tuam in Galway. This decision was “based on potential pathways references by the advocacy group Justice For Magdalenes (JFM)”.

Within eight months, HSE staff in Cork and Galway had turned up enough shocking material about both institutions that concerns were being expressed about whether or not these issues warranted a State inquiry in and of themselves.

A 20-page report was prepared by the HSE in relation to the archive of material it had in relation to the Bessborough Mother and Baby Homes. The Order running that institution - the Sisters of the Sacred Hearts of Jesus and Mary - had handed over their records relating to its operation of the institution to the HSE in 2011. They are now held by Tusla.

The HSE report reveals that as well as handing over its administrative records for the institution, the Order also provided the HSE with a death register recording the names of hundreds of children who died in its care over a period of almost 20 years.

The report points out that this register reveals infant death rates that were “wholly epidemic” and a “cause for serious consternation”.

The register shows that 470 infants and 10 women died in Bessborough between 1934 and 1953. A total of 273 deaths took place in just a six-year period between 1939 and 1944.

However, curiously, the Order reported 353 deaths to State inspectors in this period. The Commission said this discrepancy is accounted for by dint of deaths which occurred in the Bessborough Home and its adjoining maternity hospital being were separately recorded and notified.

Running to more than 50 pages, the Order's death register it lists each child’s name, date of death, former residence of the deceased, gender, age at last birthday, profession (which is marked ‘son’ or ’daughter’ in most cases), cause of death, duration of illness, initials of the officer recording the death, and the date when the death was registered.

The principal cause of death in some 20% of the deaths is marasmus (severe malnutrition).

Other causes of death in the entries include gastroenteritis, congenital debility, spina bifida, congenital syphilis, pneumonia, bronchitis, congenital heart, tubercular peritiorities, cardiac shock, heat stroke, tonsillitis, and prematurity.

“Curiously there are no death records for any years following 1953,” notes the report.

It also raises concerns that death certificates may have been falsified so that children could be “brokered into clandestine adoption arrangements, both foreign and domestic” — a possibility the HSE report said had “dire implications for the Church and State“.

The examination of the order’s own records found that the women and children in its care were “considered little more than a commodity for trade amongst religious orders”.

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.

It concludes by stating that the “interconnectedness between Church and State demands a much more comprehensive exposition than has been offered here.”

The material being found in relation to Bessborough and Tuam compelled Dr Declan McKeown — consultant public health physician and medical epidemiologist — of the Medical Intelligence Unit in the HSE to write to principal officer at the DCYA and member of the McAleese Committee Denis O’Sullivan on November 1, 2012, to warn that “adoption, birth and registration and the recording of infant mortality” were issues that may require “deeper investigation”.

As a result, the HSE report on Bessborough was not included in the final HSE submission to the McAleese Committee. While included in various earlier drafts, Denis O’Sullivan emailed then national director of Children and Family Services, Gordon Jeyes on November 7, 2012, to advise that any issues around mother and baby homes were outside the remit of the McAleese Committee.

“Material included beyond that is beyond the scope of our work — eg, the scope does not extend to an examination of other places of refuge eg mother and baby homes, other than in the context of referrals from Magdalene laundries.

If there are separate and validated findings of concern emerging from such additional research, obviously they should be communicated by HSE and through a separate process.

The previous month, Nuala Ní Mhuircheartaigh of the McAleese Committee had emailed then HSE Assistant National Director of Child and Family Services Phil Garland acknowledging the Bessborough report, but stating it was “heavily focused on broad narrative and context rather than fact.”

The Report of the Inter-Departmental Group on Mother and Baby Homes, published by the DCYA in July 2014 also failed to mention any of these concerns.

When the Irish Examiner first revealed details of the HSE report in 2015, the DCYA said it had no knowledge of the report. The department later changed its 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, the then children’s minister Dr James Reilly stated the 2012 report’s findings are “a matter of conjecture”.

While the author if the report does state that the conclusions of the report were conjecture, this was in reference to establishing the interaction between the State, the order running Bessborough and the order operating the two Magdalene laundries in Cork.

The author stated all of the issues emerging from the records demanded "a much more comprehensive exposition than has been offered here".

It was an invitation to carry out a full investigation based on examination of the Orders own records. However, nothing happened.

The HSE report, however, is rock solid on the issue of infant death numbers as they are taken directly from the nuns own register. After all, similar information uncovered by Catherine Corless a number of years later is what lead to the establishment of a Commission of Investigation in the first place.

Of course, we know that children died in the care of the Bessborough institution after 1953, albeit in far smaller numbers. It is not the number that is noteworthy, rather, the manner in which these children were buried.

In February 2018, this newspaper revealed that children in the care of the institution who died as late as 1990 are buried in unmarked graves in a Cork city cemetery.

Three grave plots in St Finbarr’s cemetery in Cork city were found to contain the remains of at least 21 children. Two of the three plots are completely unmarked. The third records just one name despite 16 children being buried in the grave.

One of the unmarked plots was purchased by the former St Anne’s Adoption Society. Founded in 1954 by the then Bishop of Cork Cornelius Lucey, it was set up with the purpose of arranging the adoption of babies born to Irish unmarried mothers in Britain. It closed in 2003 and its records transferred to the Southern Health Board. They are now in the possession of Tusla.

Buried in this plot are three girls and one boy who all died in early infancy. Their deaths occurred in 1979, 1983, 1988 and 1990. The death certificate for the last child buried in the plot in 1990 reveals that, although she died in St Finbarr’s Hospital, she was in the care of the nuns at the Bessborough Home. A birth certificate could not be located for the child in this name.

Nearby is a marked plot belonging to the former St Patrick’s Orphanage run by the Mercy Sisters. It operated a nursery for St Anne’s Adoption Society where children were kept until the society could arrange for an adoption to be contracted.

A total of 16 children are buried in this plot from between 1957 and 1978. Although the grave is marked, it does not have a headstone and just one name — that of the final child buried in the plot — is recorded on a small brass plaque attached to a small wooden cross.

Some of the children buried in this plot were born to unmarried Irish women living in Britain. They had been sent back to be adopted by Irish families. Some of the children have been buried in the names of their putative adoptive parents.

However, three of the 16 were from the Bessborough Mother and Baby Home. Death certificates for two infants in the plot reveal that they died at the institution, while in another case, the child is listed as having been born in Bessborough but died in St Finbarr’s Hospital.

In another part of the cemetery, another little girl in the care of Bessborough who died in 1989 is buried in another unmarked grave. This is recorded as a non-perpetuity plot indicating that it does not have an owner. In short, a paupers grave.

The discovery also threw up a problem with the terms of reference for the current inquiry as it would appear not all of these deaths can be investigated

It seems obvious that they all should be. After all, all of the children are representative of the cohort of infant deaths that it is charged with examining - namely the children of unmarried mothers that who were destined for adoption until they died and were buried in unmarked grave plots.

All but one of the deaths are in plots owned by a formerly State-accredited adoption agency — St Anne’s Adoption Society, which closed in 2003 — and by the St Patrick’s Orphanage, which operated as a nursery for St Anne’s Adoption Society. The problem is neither institution is listed as institutions under the commission’s remit.

In fact, of the 21 infant deaths uncovered during the Irish Examiner investigation, just five of those children were linked to an institution which falls under the remit of the commission - Bessborough Mother and Baby Home.

While all of the deaths are indicative of the same issue, involve the same cohort of women and their children, the same lived experience, only the five that are linked to a mother and baby home which is under investigation can be examined.

For its part, Tusla declined to say whether or not they reported these deaths to the Commission before the Irish Examiner raised the matter.

What is clear is that Cork city cemeteries were used by the Order to bury infant remains.

ILLEGAL ADOPTION

It's clear that the records now held by Tusla in relation to Bessborough contain records relating to questionable adoption practices.

The HSE said as much as far back 2009. Throughout 2009 and 2010, 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, the latter was determined to secure indemnity against legal action on any records it was to receive.

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.

The following year, a HSE social worker revealed in 2011 that Bessborough Mother and Baby Home files contained information on the “quasi-illegal deportation and adoption” of children to the USA, Britain, and Australia.

The revelation is contained in a business plan prepared by principal social worker in the South Lee region, Pat O’Dwyer, in 2011 in preparation for the HSE’s takeover of the records.

Mr O’Dwyer pointed out that the natural mothers and adopted people had been “badly treated, rebuffed, misled, and in many cases dishonestly misdirected” when seeking information.

One of those women badly treated by both the nuns and the State right into the present day is Jackie Foley*.

Jackie was just 16 years old in 1974 when she signed a consent form in Bessborough Mother and Baby Home form to have her son adopted. However, she did not sign her own name on the form.

Instead, under instruction from and nun, she signed the name Micheline Power* - a woman who does not exist. Her mother and a solicitor were also present in the room.

The writing of that signature led to all of the documentation used to eventually secure an adoption order being deliberately falsified – including her son's baptismal certificate and birth certificate.

Documents seen by the Irish Examiner reveal, and indeed name, individual nuns who worked at the Bessborough Mother and Baby Home and the affiliated Sacred Heart Adoption Society (SHAS) who were party to this.

Jackie’s son is now 44. If he was to access his original birth certificate, which in Ireland he still cannot as a legal right, he will spend years searching for his mother under the name of a woman who does not exist.

If this wasn't bad enough, the treatment of Jackie as an adult woman by various State agencies has been no better.

Take Tusla for example, who now hold the records which reveal what happened to her as a teenager.

Just last year, staff handling Jackie’s case were instructed in emails not to refer to situations like hers as “illegal” but instead as “possible illegal registrations”. Reference is made to having to “hold our powder” because “that stuff is FOI’able... and it could be used against us if someone takes a case”.

Staff are told that the Adoption Authority of Ireland (AAI) are the only ones that can make a determination as to the legality or illegality of any adoption.

In February 2017 Jackie’s son is now 44. If he was to access his original birth certificate, he will spend years searching for his mother under the wrong name. He will be looking for Micheline Power — a woman who does not exist.

But the historic treatment of Jackie replays in the present. Almost half a century later, the attitude of certain State agencies — the Adoption Authority of Ireland (AAI), and Tusla — to her case is as cold-hearted as the nuns who forced her as a 16-year-old to sign away both her and her son’s identities.

Instead of offering support or offering assistance, emails between staff members show the attitude of Tusla to be one of institutional self-preservation.

Just last year, staff handling Jackie’s case were instructed in emails not to refer to situations like hers as “illegal” but instead as “possible illegal registrations”.

Reference is made to having to “hold our powder” because “that stuff is FOI’able... and it could be used against us if someone takes a case”.

Staff are told that the AAI are the only ones that can make a determination as to the legality or illegality of any adoption.

In February 2017, a principal social worker at the AAI wrote to Tusla stating that in the case of Jackie's son, “the adoption is a legal adoption”.

The AAI social worker made this determination despite the fact that it is a fully documented case where an illegal registration has resulted in the granting of an unlawful adoption.

Jackie’s case told the AAI’s predecessor, the Adoption Board, about her case as far back as 2005.

Neither reported the case to the gardaí, not in 2005 when first notified, and at no point since. As a result, Jackie herself reported the details of what happened to the gardaí earlier this year.

Ten years later, Jackie’s case was forced onto the AAI and Tusla’s radar when she sought access to her records in 2015. Again, no one in either agency reported the matter to gardaí.

Jackie was not much older than a child when she was taken to Bessborough as a young, frightened teenager.

Details from maternity register for the institution, released under freedom if information, revealed that girls as young as 12 – pregnant as a result of rape – were in Bessborough into the 1980s.

The youngest child in the registers dates from 1968. The girl is listed as being just 12 and had been transferred from Bessborough to St Finbarr’s Hospital in Cork, where her child had been stillborn in January 1968, as a result of “ante-partum haemorrhage”.

However, the presence of children in Bessborough pregnant as a result of rape continued into the 1980s. For example, Maternity Record Book 40 lists a girl of 14 whose child was stillborn in 1982. The record simply states the child “premature 33wks, gasped and died”.

VACCINE TRIALS

The alteration of information in records is another feature of the various revelations made in this newspaper about Bessborough Mother and Baby Home.

Material obtained by the Irish Examiner in 2016 showed that the files of children used for vaccine trials carried out at the institution were altered in 2002 – just weeks after the Commission to Inquire into Child Abuse (CICA) sought discovery of records from the Sisters of the Sacred Hearts of Jesus and Mary

It had sought discovery of the records from the Order on July 22, 2002. An affidavit was sworn on October 3, 2002, and on a number of later dates in 2002 and 2003.

The document listing the changes opens with: “8.8.02 Checked the 20 files.” This is immediately followed by: “9.8.02 Made the changes.” The changes made to files Nos 5, 8, 11, 12, and 15 to 20 are then detailed.

The changes include:

• The alteration of discharge dates of mothers (by a period of one year and two years);
• The changing of discharge dates of children;
• The changing of admission dates of mothers;
• The alteration of the age of a mother (by two years);
• The alteration of dates of adoption;
• The changing of baptism dates and location of baptism;
• The insertion of certain named locations and information into admission books.

A data protection request released to Bessborough vaccine trial victim Mari Steed in 2011 also confirms this timeline.

A file listing details about both her and her natural mother was created on August 6, 2002.

This was done following a request “for Solicitor re Vaccine”. Ms Steed’s natural mother is listed as “No 19 on Doctor’s List”. The record lists “All Counties DUBLIN” above discharge information pertaining to her mother.

The document listing the changes notes that this information was inserted into Ms Steed’s original file.

The entry reads: “No 19 [house name redacted] Crossed out the Indoor Reg entry as it is corssed (sic) out in the Book. Inserted DUBLIN after All Counties.”

Another entry reads: “No 17 [house name redacted] Changed nm [natural mother] disch from x/x/60 to x/x/62”.

Given that the trial took place between December 1960 and November 1961, this change has the effect of placing this woman in Bessborough during the period her child was vaccinated.

If she was, in fact, discharged from Bessborough at the date given in 1960, she could not have been present to consent for her child to have been part of the vaccine trial.

The question of consent was the key issue being examined by the CICA’s Vaccines Module before it was shut down in 2003 following a Supreme Court ruling.

A statement from solicitors representing the Order stated that it had “no immediate knowledge of any specific event” concerning alterations made to records.

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

In a separate statement, the order said it wished to “categorically state that no documents were altered”.

“In your recent correspondence, you are suggesting that something illegal or inappropriate had occurred in regard to the documents to which you refer,” said the statement.

This is entirely untrue, and we will continue to deal directly with the official commission on all such matters.

In 2017, the Irish Examiner revealed that a previously unknown trial of lactose and baby formula was carried out using infants in Bessborough Mother and Baby Home by Glaxo Laboratories in the mid-1970s.

The extend of vaccine trials on children in care in Ireland by British pharmaceutical companies on children in care in Ireland has slowly been emerging through the media over the past 20 years.

These tests involved the trialling of various vaccine combinations by predecessor companies of pharmaceutical giant GlaxoSmithKline (GSK) — Glaxo Laboratories and Burroughs Wellcome.

These revelations generated more questions than answers — answers it is hoped the Mother and Baby Homes Commission can provide.

However, the fact that Glaxo Laboratories was also trialling other products on children here — namely lactose and baby formulas - is a new discovery.

A trial sheet obtained by the Irish Examiner revealed that Glaxo Laboratories carried out a “clinical acceptability and safety trial” of “Golden Ostermilk and Lactose”, while a separate trial sheet reveals a trial of “overseas milk powders (by 0111)”.

The “clinician responsible” for the tests was Eithne Conlon — a local Cork GP who worked with Bessborough for many years.

The trial sheets recorded a range of reactions to the products. These included vomiting (slight, moderate, severe, or none), excessive regurgitation, wind (slight, moderate, severe, or none), stools (locae, normal, or constipated) and stool colour (yellow, grass green, olive green, yellow green, no stools, meconium, changing).

Other “abnormal conditions” were also noted. These included excessive crying, irritability, napkin rash, thrush, and others.

The latter trial sheet was contained in the records of Breda Bonass, who had sought information on her medical history from Tusla under Freedom of Information.

The former only came to light when Ms Bonass sought further information from Tusla.

However, the trial sheet for “Golden Ostermilk and Lactose” was also found in the antenatal records of other women — and all contain identical details including patient numbers — something which the FOI officer told Ms Bonass was “perplexing”.

Ms Bonass asked the Sisters of the Sacred Hearts of Jesus and Mary and GSK for an explanation.

The nuns responded via their solicitors, telling her they no longer held the records nor had any access to them and that she should go to Tusla.

GSK’s UK data protection section informed her that the data had been “destroyed” as the “retention period has already expired some years ago”.

It told this newspaper it was “unable to locate any records relating to a 1974 study” but that it had located records relating to a trial from 1967.

The assumption, therefore, would be that the 1974 study’s purpose was to compare current milk powder with a newer formulation.

"The records contain no names or information about the children involved,” said GSK in a statement.

With regard to the consent of mothers, GSK said that, due to the fact that it had no records, it could not confirm who gave consent but that its assumption was that it would have been “those Sisters running the homes as the legal guardians”. Obtaining consent would been left to the doctor conducting the trial.

GSK said the identical sheets were probably blank forms or templates and that the information entered “appear to be codes, possibly relating to a spreadsheet collating all responses”.

It also confirmed that this was the first time it was made aware of this study and that it had not been asked to disclose it in any official capacity, “as this is clearly outside of the current Commission’s [Into Mother and Baby Homes] vaccines inquiry”.

The Commission is only tasked with examining vaccine trials carried out by GSK legacy companies, not other forms of product testing that may have occurred.

The inquiry has now been delayed until February 2020. The delays have caused anger to many of the survivors representative groups desperate for answers and justice. The above revelations relate to just one of the homes under its remit. It is looking at many more and, undoubtedly, has access to hundreds of thousands more records.

The issue of Mother and Baby Homes, forced and illegal adoptions, infant deaths and the myriad of practices surrounding the confinement of thousands of women in Ireland are often spoken about as part of Ireland's past. They are not. The fact we still don't fully grasp the enormity of what happened shows this is a story with contemporary relevance.

The more you investigate these matters, it is often more questions that emerge - not answers. The Commission has another 12 months to find them.