The delivery of high quality, safe services is a priority within the Irish healthcare system. This is in line with the Sláintecare vision of Right Care. Right Place. Right Time. Serious adverse events when they occur in the health service have a devastating impact on the families concerned.
It is vital that our health services take steps to ensure serious adverse events are appropriately reviewed and responded to at a national level, including the provision of appropriate supports for patients and families throughout the process. An integral part of this is the appropriate and timely reporting of adverse events when they do occur. This information is important for healthcare services to learn so that care and experiences for patients and their families can continuously improve.
The Coroners are independent, quasi-judicial office holders whose core function is to investigate sudden and unexplained deaths so that a death certificate can be issued. The exercise of these statutory powers by a Coroner during an inquest is entirely a matter for the relevant Coroner.
Within this context the HSE has systems and procedures in place to respond when an adverse incident occurs. This approach to incident management is cognisant of the needs of those affected and supports services to learn and improve. I have referred this to the HSE for a response on the operational matters.