Dáil Éireann debate -
Thursday, 17 Apr 2008

Vol. 652 No. 1

Hospital Services.

Deputy Caoimhghín Ó Caoláin

Every week since the Dáil resumed at the start of this year has brought news of more cuts in our public health services as a result of the disastrous policy of this Government and disastrous management by the Health Service Executive. These cuts have come on top of the policy of over-centralisation which attacks the services provided at local hospitals. Nowhere has this been done more ruthlessly than in counties Cavan and Monaghan where our two hospitals are now facing what consultants at Monaghan have described as "a catastrophic situation."

What is the Minister for Health and Children doing about this? She is driving it. Her priority is privatisation. Next week, on 24 April, the Minister will open a private health conference in Dublin and participants will pay more than €500 each to attend this exclusive event for private health profiteers. Meanwhile, our patients are suffering and our public hospitals are being downgraded.

The latest crisis for Monaghan General Hospital has been provoked by the attempt of HSE management to discontinue the ventilation facility at Monaghan General Hospital which was due to close on 7 April. The closure has not taken place because consultants at Monaghan are refusing to operate proposed new protocols for the treatment of patients requiring acute care. The consultants say that the removal of the ventilation facility will lead to the ending of all acute medical admissions in Monaghan resulting in "mortality for patients".

Correspondence from the consultants at Monaghan General Hospital to Health Service Executive management shows that the hospital is facing, in the words of the medical professionals, "a catastrophic situation". If the HSE is allowed to proceed with its plan to end all acute medical admissions at Monaghan General Hospital, then facilities will have to be found for the treatment of the 3,000 per annum acute medical admissions to Monaghan. The main burden will fall on Cavan General Hospital which already has to cater for 5,000 such admissions per annum and which currently has 160% bed occupancy. In other words, it has 60% more patients awaiting beds than there are beds available in the hospital.

The consultants make clear that with only some 25 additional beds proposed for Cavan, the proposed downgrading of Monaghan is totally untenable. I commend the Monaghan consultants for refusing to agree and operate the protocols proposed by the HSE. As a result of their stand, the HSE has not been able to enforce the closure of the Monaghan ventilation facility.

An existing protocol, not previously known publicly, states that Monaghan is only allowed to have three patients on trolleys awaiting admission at any one time. If a fourth patient presents he or she must be moved to Cavan or another hospital. This has nothing to do with patient care. All it does is disguise the true need and demand for the services at Monaghan. In the first three months of 2008 some 78 patients were moved from Monaghan in this way. It is interesting to note that 18 patients left Monaghan untreated rather than go to another hospital. This protocol serves only to disguise the true need and demand for services at Monaghan General Hospital.

Just as significant as the strong protest from the consultants about the proposed ending of acute medical admissions is their assertion that since returning "on-call" in 2005, Monaghan General Hospital has functioned very well and provided a high standard of care to patients with acute medical illnesses. This reflects the positive experience of the overwhelming majority of people, this Deputy included, in the area served by the hospital.

All of this unquestionably gives the lie to the utterly false and misleading claims by HSE management and the Minister for Health and Children, Deputy Mary Harney, that the downgrading of Monaghan General Hospital is based on patient safety and achieving better standards of care. It is clearly no such thing. It is driven by cost-cutting and a ruthless centralisation agenda. The HSE is enforcing flawed strategic plans in the most high-handed manner, regardless of the impact on patient care. This correspondence exposes how bureaucrats have sought to enforce protocols for the care of patients against the wishes of the medical professionals who have to deliver that care.

The implications of the HSE plans are very serious for Cavan General Hospital. It will not be able to cater for 8,000 acute medical admissions per annum. Any notion that somehow Monaghan's loss is Cavan's gain is totally spurious. Patient care in both counties and in the north-east region will be adversely affected. For the sake of both hospitals and all who depend on them these plans must be resisted.

GPs in County Monaghan have written to Mr. Stephen Mulvaney, network manager of the HSE in the north-east region, and they state that patient care is not at the centre of HSE decision making. Those are the professional colleagues of the Minister of State, Deputy Devins.

Monaghan General Hospital is the victim of political decision-making on health care at Government level which takes no account of the reality of people's lives. I will conclude by making it abundantly clear that I will continue to challenge the Taoiseach, the Minister for Health and Children, Deputy Mary Harney, and all their Fianna Fáil and Green Party Government colleagues on this matter and I urge people throughout counties Cavan and Monaghan, irrespective of their political affiliation or none, and beyond both counties and that region, to challenge Government and Government-supporting Deputies on this disgraceful set of proposals which will be a template employed on hospital networks throughout the rest of the jurisdiction.

Deputy Jimmy Devins

I am taking this matter on behalf of my colleague, Deputy Mary Harney, Minister for Health and Children. I thank Deputy Ó Caoláin for raising this issue.

The Health Service Executive north-east transformation programme involves widespread and fundamental change and is designed to build a health system that is in line with the model of care emerging internationally. The programme is expected to deliver an integrated care system with local and regional hospitals functioning within a co-ordinated, integrated clinical network as part of the wider system of primary, community and continuing care. Its overriding aim is to improve safety and achieve better standards of care for patients in the region.

The HSE has advised that the north-east transformation programme is approaching the end of its initial phase of detailed planning and is moving towards detailed design and implementation. Operational management and transformation management arrangements in the region have now been linked in order to achieve full integration of the transformation programme with the management of operations. The HSE has emphasised its commitment that existing services in the region will remain in place until they are replaced with higher quality, safer or more appropriate services. The HSE further advises that no decisions have been taken on reducing services in the north east.

The HSE is facing a challenging year and is exploring, in the case of the north east, how best to deliver on service plan targets within the level of resources available. The Teamwork report clearly states that there is a role for all five hospital sites in the development of acute hospital services in the future. The report clearly indicates that the current service configuration is unsustainable and that there needs to be a reconfiguration of hospital services across the five hospital sites and, ultimately, the development of the new regional hospital in order to ensure the highest level of patient safety.

There are a number of factors influencing the direction of these developments, not least the need to ensure that there are fully trained teams of emergency medical and surgical staff available to deal with the most complex cases which will present in the region. In the case of Monaghan General Hospital there have been a number of significant improvements, including two newly refurbished inpatient medical wards. This project, which cost €5 million, consists of two 25 bedded in-patient wards — male and female — with each ward providing a range of multi-bedded and single rooms. The ward project builds on the investment of €1.2 million on new equipment, an upgrade of the pharmacy and general facility upgrades for the hospital.

The HSE envisages that the role of Monaghan General Hospital in the future will be to provide a range of diagnostic, outpatient, day cases and some in-patient treatment services within clinical networks. Significant developments have also taken place in the provision of surgical services across the Cavan-Monaghan Hospital interface. Emergency surgical services on a 24-hour, seven day basis are provided on the Cavan site while significant elements of diagnostic, outpatient and day case services are provided on the Monaghan hospital site. This has resulted in lower waiting times for outpatient appointments and inpatient elective services. Since the reconfiguration of Cavan-Monaghan surgical services, patients can be seen by the visiting consultant surgeon on the day of referral by the general practitioner. The HSE has indicated that the relevant clinical protocols for the development of a minor injuries treatment unit at Monaghan hospital are currently being developed by the emergency care clinical network in conjunction with Cavan-Monaghan hospital group management.

Monaghan hospital will continue to have an important role to play in the provision of health services in the north east. This view was confirmed in the Teamwork report and also in the north-east transformation programme.

Deputy Caoimhghín Ó Caoláin

Protocols are being developed by management. Does anything else say it as clearly?

Deputy Thomas Byrne

It is with particular sadness that I speak today. A young expectant mother, who lived in the same estate as myself, died in childbirth. Her family and the wider community were in shock and deeply saddened. Let me, therefore, first express my sympathies with the family of Tania McCabe — her husband Aidan, their children, and the families of Aidan and Tania.

When this happened my personal amateur, non-medical reaction was that it must have been the kind of devastating and unfortunate accident which sometimes happens in medical practice. As a nurse, my wife's immediate reaction was that this should not happen in Ireland or in the western world. How right she was. This should not have happened in Ireland.

A report made by the HSE was leaked, as usual, to the media before we legislators saw it, although in this case it seems the family saw it before it reached the newspapers, unlike other cases such as the recent cancer scare. The report paints a devastating picture of the quality of maternity services at Our Lady of Lourdes Hospital in Drogheda. According to newspaper reports, which are what I must rely on, staff shortages, high workloads and systems failures contributed to death in this case.

Will this happen again? As a father of a child born in Our Lady of Lourdes Hospital in Drogheda six months ago, and who has such hopes for some time in the future, I have no reassurance. The Government, as the Minister of State, Deputy Devins, will be conscious, has a duty to protect our people. I have regularly defended medical services at the hospital and I will continue to defend and praise the midwives and doctors, many of whom I know, but I cannot stand over the systems and the numbers of staff in place. According to newspaper reports, the HSE report states — speaking of the medical staff in general, I think — that their practice and, ultimately, the care that they provided to Tania was compromised by their workload and the environment in which they were working.

The report also identifies shortcomings in record keeping, according to the media. This seems to be a perennial problem when we come to hospital issues. The HSE press release says the HSE will move quickly to look at the recommendations on how best to approach their implementation. This has been said before and must be said. We have heard from the Kinder task force, An Bord Altranais, Judge Maureen Harding Clark and the medical board of the hospital itself. A consultant recently offered to pay for staff out of his own salary. People die in hospital, but in this case it seems that HSE systems contributed to the death in question. I say "seems" because we are relying on media reports and I do not want to intrude on the family's grief.

I will paint a picture of the estate in which we live. It is a brand new estate of perhaps 1,000 houses. Many of the people who live in the estate are, like my wife and I, young couples with young children. There are lots of mothers on maternity leave walking around the estate with their newborns. They are very happy people. One home in that estate has been left bereft of a wife and mother. It is a very sad situation. The Government and myself, as a Deputy for that area, estate and constituency, have a responsibility to get things right.

Deputy Jimmy Devins

I am taking the matter on behalf of my colleague, Deputy Mary Harney, Minister for Health and Children. I thank Deputy Thomas Byrne for raising this very sad issue and extend my sincere sympathies to the family of the deceased at this difficult time.

I understand that an internal review of the circumstances pertaining to the death of the lady concerned and her infant son at Our Lady of Lourdes Hospital, Drogheda was carried out. The scope of the review covered the period from the woman's first antenatal specialist consultation in November 2006 to the time of her death and the death of her son in March 2007. The review team was chaired by a consultant obstetrician and its membership included a consultant anaesthetist, a director of midwifery and the risk assessor for the HSE north east. The review group was asked to examine protocols and procedures relevant to the incident, taking into account prevailing standards of best practice, and to prepare a written report for the HSE north east hospital network manager to include such recommendations as it saw fit.

The Department is advised that the review has now been completed and that the resulting report has been given to the family. The family has also been offered professional support at this most difficult time. Relevant hospital personnel have also been briefed on the contents of the report and its recommendations. The HSE has said that it is assessing the recommendations as a priority. I also understand that the coroner is due to hold an inquest in respect of the case.

The enhancement of maternity service provision and development in Our Lady of Lourdes Hospital is being addressed. For example, three additional consultant anaesthetists were appointed in 2007, which has facilitated the provision of dedicated consultant anaesthetist obstetric cover seven days per week. The HSE has also approved an additional 22 midwives. This has raised the approved midwifery staffing complement to 88.6. I understand that all but six of these posts have been filled. Along with the increases in staffing levels, the HSE advises that it has strengthened the governance and communications structures to address some of the main issues highlighted during the review. I understand that the Minister does not propose to comment further at this time out of respect for the deceased and the family.

Child Protection Issues.

Deputy Alan Shatter

I thank the Acting Chairman for the opportunity to raise this issue. In the brief time available, I will only be able to touch on some of the issues that arise out of the publication of what is known as the McElwee review report. It is a damning indictment of Departments and State agencies in respect of their abysmal failure to comply with the Children First guidelines, which were specifically put in place to provide protection for children.

It is clear that there is no point in making a contribution if the Minister of State is not even listening to me. I am sure he has a prepared script for response but this procedure becomes even more futile if he is not listening. With the chance that he might reply to something I raise, I will continue.

A litany of failure has been set out in this report, which is one of many we have seen which illustrate the incapacity of the State and its agencies to ensure that the guidelines it put in place for child protection are properly complied with. We require explanations that are not provided by this report.

I will refer briefly to some matters contained in the report. It is clear that at an early stage the central authority for mutual assistance in criminal matters, based in the Department of Justice, Equality and Law Reform, received correspondence from the Dutch authorities informing it that Dr. A "sexually harassed American girls, two of them being 18 years old and one of them being 16 years old" in Amsterdam. An inquiry was made of the Department as to whether a prosecution could take place in Ireland. That was referred to the Director of Public Prosecutions who said it could not. Subsequently, the same section in the Department was requested in August 2005 to serve a summons on Dr. A for a court session that took place on 13 September 2005. Those court proceedings resulted in his conviction for a sexual offence.

It seems that although this was an Irish national who was engaged in sensitive work and indeed was undertaking research into child protection issues, it never occurred to the Minister for Justice, Equality and Law Reform, any official in his Department or any official who had received the original letter or the request to serve the summons to inquire into the outcome of that prosecution. The Department of Justice, Equality and Law Reform explains its failure to communicate anything to anybody after 2005 on the basis that it was not made aware of any detail of the conviction. There should be an obligation on the Department to inquire into the detail of the conviction and what occurred. If the Department had applied the Children First guidelines, it would have been required to ensure that if Dr. A was working in a position dealing with children, proper information was furnished. I want an explanation for the failure on the part of the Department and an assurance that in similar circumstances it will not behave similarly.

We then have what can only be described as a damning indictment of the Midland Health Board and the HSE midland area. The HSE midland area and the health board are the bodies which are primarily responsible for child protection. They have a statutory duty to protect children's welfare. At a very early stage in 2004, a top official in that health board was advised of the allegations made against Dr. A. Indeed, the outcome of the summons and the conviction were made known to him. Yet, incredibly, that health board continued to commission work from Dr. A into child protection issues and, amazingly, in the context of publishing one report, subsequently had the Minister of State at the Department of Community, Rural and Gaeltacht Affairs, Deputy Noel Ahern, present, presumably to give the Government imprimatur to his piece of research.

The report concludes:

Having regard to all of the facts available in respect of Dr. A's behaviour in Amsterdam in June 2004, the absence of any recorded risk assessment in respect of Dr. A, and the absence of any recorded "closure"of the Amsterdam incident for the Midland Health Board, it is inconceivable that an Officer of the Health Board would continue to make decisions to fund various projects involving Dr. A, particularly where they would involve young persons. The fact that at least one of those arrangements, incomplete and apparently entitled the Youth Resilience Project, was with Dr. A in a private capacity, and secured outside of any evident tendering or procurement procedures, raises serious concerns and requires further separate inquiry through the HSE’s Internal Audit System.

It raises more than that. This reports lists a litany of failures on behalf of a number of officials of the Midland Health Board and the HSE. No one is held accountable for anything. I want to know whether anyone has resigned and whether the official known anonymously and euphemistically as MHB 1, who was at the centre of everything that occurred in the context of the total failure to abide by the Children First guidelines and the continued commissioning of Dr. A, despite information indicating that he was inappropriate to undertake research, is currently working in the HSE, in what capacity and whether his or her work has anything to do with children. Has he or she resigned?

The problem with this report is that it contains a litany of failure and the anonymity of departmental, health board and HSE officials is preserved. No one is held accountable. The truth is that no one, including this Government, cares. I ask the Minister to ensure that those issues are followed up and that the recommendation contained in this report that the Children First guidelines be given a statutory base be put in place. The report itself complains that where the guidelines are breached, there are no consequences. There should be consequences.

Those working in these areas need proper training to ensure they adhere to guidelines the Government put in place to protect children. What training is currently taking place to ensure that people in positions of management in the HSE, the Departments of Justice, Equality and Law Reform, Education and Science, Health and Children and in other relevant Government agencies are not only aware of the Children First guidelines but understand their obligations to comply with them and are advised that there are consequences if they fail to do so?

Deputy Jimmy Devins

I thank Deputy Shatter for raising this issue and welcome the opportunity to respond on behalf of my colleague, Deputy Brendan Smith, Minister of State with responsibility for children, who is in Armagh at a North-South function and cannot attend the debate.

The Minister welcomes the publication by the Health Service Executive on 15 April 2008 of the review inquiry into child protection issues touching on or concerning Dr. A. When this issue came into the public domain in July 2007, the Minister instructed the HSE to carry out an immediate review of how the relevant authorities responded to an incident in Amsterdam involving Dr. A and his subsequent conviction in 2005. The Minister wishes to stress that the HSE report does not imply a general failure to operate the Children First guidelines across the public service, but only shows that in some instances the guidelines were not followed.

A key finding of the HSE review clearly states that Children First — the National Guidelines for the Protection and Welfare of Children, was not followed in at least some instances, once the situation concerning Dr. A's trip to Amsterdam came to light. The Minister welcomes the finding that if the guidelines had been followed, as stated in the report, then "timely and clear outcomes in a child protection context would have been achieved". This is a strong endorsement of the guidelines as they stand. The Minister believes, however, that lessons can be learned from this case. The review of Children First currently being undertaken by his office will carefully consider the recommendations of the report and take account of same in finalising the review, which is nearing completion. On the Minister's instruction a high level group has been established, comprising officials of the Office of the Minister for Children, the HSE, the Garda Síochána and the Departments of Justice, Equality and Law Reform and Education and Science. The group will meet as soon as possible to ensure that there is a fuller awareness of child protection policies, guidelines and procedures, and to explore how the current arrangements under Children First can be improved upon.

In the light of the publication of the review, there has been some commentary on the need to place Children First on a statutory basis. The Minister believes the conclusions of the review to be a clear vindication of the existing child protection guidelines. Co-operation between the HSE and State agencies has been improved upon since the incident in 2004. It can be argued that a statutory route could be problematic, as it might place extensive administrative burdens on relevant bodies and organisations and actually slow up the notification process.

Deputy Alan Shatter

Complete nonsense.

Deputy Jimmy Devins

In some jurisdictions where a statutory arrangement is in place, there is anecdotal and indeed research evidence that such problems have been encountered.

Deputy Alan Shatter

Instead, the guidelines are entirely ignored.

Deputy Jimmy Devins

The consideration of putting the Children First guidelines on a statutory basis will be taken account of in the review which is nearing completion in the Office of the Minister for Children. This is a complex area which has been the subject of serious consideration by previous Ministers with responsibility for children. Any such decision could not be taken lightly as there is international evidence that such an approach has both positive and negative consequences associated with it. What is important now is to ensure that Children First, as it currently operates, is as effective and robust as possible in facilitating child protection.

Training and education, together with good recruitment and child protection policies in line with Children First, in all relevant agencies is most important in ensuring child protection, and the HSE has undertaken in its response to this report to address these issues, particularly training and education. The report has been referred to the HSE's human resources directorate to determine what, if any, implications there are under the HSE's human resources policies, and the Minister welcomes that. In addition to the meeting between the Office of the Minister for Children and relevant stakeholders, the finalisation of the review of Children First, which commenced after the Ferns Report, is an ideal opportunity to ensure that the guidelines are updated and improved as appropriate in the light of the Dr. A inquiry. It is important to note that the Children First guidelines, although not on a statutory basis, are Government approved guidelines which bring with them very clear responsibilities for those who become aware of child protection issues.

The Dáil adjourned at 5.25 p.m. until 2.30 p.m. on Tuesday, 22 April 2008.