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Dáil Éireann debate -
Wednesday, 10 Mar 2010

Vol. 704 No. 4

Leaders’ Questions.

What has been exposed at Tallaght hospital is perhaps the best example of the national failure of this Government. It is one of the best examples of the abject failure of the Minister for Health and Children to live up to the responsibility for immediate care that was given to her following her appointment to that position. It is unconscionable that a number of people — more than twice the population of County Leitrim — should not have their X-rays read over a four year period. It smacks of a gigantic cover up that only those who had problems would be informed. We now know that one person has died, another is being treated for cancer and there is a possibility that many people are walking around with undetected tumours or other problems because X-rays have not been read by radiologists.

This follows a long litany of incompetence and disaster presided over by the Government in the Department of Health and Children and in other Departments. Will the Minister come into the House today to answer questions about this? Is she in New Zealand a week before St. Patrick's Day? Is the Taoiseach satisfied that she took appropriate action when it was brought to her attention by the chief executive of Tallaght hospital last December and flagged by GPs last summer?

The Minister for Health and Children is on Government business in New Zealand, meeting people in the health sector and dealing with general economic issues as well.

Is she coming back?

The St. Patrick's Day issues arise this weekend in New Zealand, rather than on St. Patrick's Day itself.

That is some round trip.

We all have to act with a sense of responsibility on the Tallaght hospital issue, rather than engage in things like some of those opening remarks.

The Taoiseach should not lecture us.

X-rays should normally be seen and formally reported by a consultant radiologist. However, since that does not appear to have happened, all the relevant X-rays are being examined by consultant radiologists on a precautionary basis. In the great majority of these cases, the X-rays were seen by doctors involved in their care, such as in orthopaedics where the doctors in the fracture clinic would look at the X-rays while seeing the patient. However, this practice was below appropriate clinical standards.

The CEO of the hospital got involved to clear the backlog following his appointment in December 2009. The CEO arranged for the additional consultants and administrative support. He monitored the situation through weekly progress reports that show the backlog was reduced from 57,921 to 23,169 by 9 March. He now states that the backlog will be cleared entirely by May 2010.

This problem originally came to light in early 2009. It appears that there are two patients who had a delayed diagnosis within this cohort. One of these patients is under treatment in the hospital for cancer. The other patient died at the hospital last summer, and the CEO was only made aware of this yesterday. He is reviewing the file on the cause of death. For any patient who needs a review of a diagnosis as a result of the review of the X-rays, all the necessary services will be made available immediately by the hospital.

The HSE has announced that it is to carry out an investigation into the circumstances that led to the accumulation of unreported X-rays at Tallaght hospital, that is, X-rays not read by radiologists. The investigation is to be chaired by a person independent of Tallaght hospital and the HSE. The details of the investigation will be announced in the coming days. The CEO of Tallaght hospital, Professor Conlon, supports the investigation and the HSE is fully supportive of Professor Conlon and the management team at Tallaght hospital in dealing with the outstanding X-rays.

The Department of Health and Children has worked with the HSE on the development of a serious incident management protocol, and it has guided the clinical management of this issue. This protocol puts patients' interests first and foremost in all actions to be taken. The Minister has provided the accountability mechanisms, such as HIQA, which ensure that where incidents arise, they are properly dealt with.

Does the Taoiseach feel guilty?

It is very difficult to verbalise the impact on people who had X-rays carried out in Tallaght hospital and who possibly have serious problems. We know that one person is being treated for cancer and that another person died. There may well be some who have tumours that have not been detected because the X-ray has not been read by a radiologist.

Can the Taoiseach supply me with the list of engagements of the Minister for Health and Children that deal with Enterprise Ireland and the creation of jobs here? I take his point about Ministers going abroad to deal with job creation for our country.

The Taoiseach states that the Minister has done much work in setting up HIQA and so on. However, this problem was flagged in 2008 and it was brought to the attention of the Minister for Health and Children and the HSE that there was a shortage of radiologists in Tallaght Hospital. According to the facts supplied to me by Deputy Hayes, Tallaght hospital has 631 beds. There are 78,843 attendances at the accident and emergency department and 226,493 attendancesat the outpatients' department. They have 12 radiologists. St. Vincent's Hospital has 16 radiologists and Cork University Hospital has 12.

My problem with the Government is that while this catastrophe unfolds around us its Minister for Health and Children is in New Zealand but she has a duty of immediate care that when something is brought to her attention she should act swiftly and in the best interests of the people and of our country. What did she do? She washed her hands of it and decided not to meddle, and we know that one patient died last year.

Why were radiologists from across Dublin not called in to deal with this backlog? Can the Taoiseach confirm that this practice of X-rays being taken and not read by radiologists for six, eight, ten or 12 weeks, or six months, is not continuing in other hospitals throughout the country? Can he confirm that the reason this practice was not exposed until now is that there was no intention of telling individual patients about their X-ray with the exception of those who had a serious problem? Can he confirm also that he is happy with what the Minister for Health and Children did in this respect because she said it was not appropriate for her to meddle in this matter, find out anything or take action that would ensure this will not happen again? Is the Taoiseach happy with his Minister for Health and Children and the action she took? Obviously, he cannot move her from the Cabinet because he cannot rely on her vote. This is a national catastrophe and is the best example of abject and blatant failure by the Taoiseach's Government and his Ministers. Is the Taoiseach happy that the Minister took appropriate action to deal with a national scandal?

Deputies

Hear, hear.

I refute totally the approach Deputy Kenny is taking in regard to this matter.

The Taoiseach refutes everything.

(Interruptions).

An Taoiseach, without interruption.

I would like to reply.

The Taoiseach said it was facile to raise questions in this House.

The Deputy has made a number of assertions and, in my opinion, some irresponsible statements which I would like to address——

The Taoiseach should call his Minister for Health and Children and ask her to resign.

——whenever his party members will allow me to speak.

They are concerned about this issue.

Deputy Allen, please.

The concern is as follows.

Who is responsible for it?

I want to make the position clear. When a serious incident such as this one arises the first action that must happen is that the practice stops or, in this case, what was not happening should begin to happen, to make sure that the 30,000 new patients coming in in recent months are properly attended to and that their X-rays are signed off by a radiologist. That was happening. The second part of the issue is to make sure that a clinical review is done. There is no suggestion or question of a cover up. We must be clear about this. What is then done is that in the interests of patient care a full clinical review is carried out, all of those X-rays are examined and if there are people affected they should be notified, having completed a clinical review. We can then say to everybody else that they are not affected in any way by this and the people who have been identified who must be spoken to are spoken to, as well as their families. That is the primary focus of what must be done.

Let us be clear about this issue. There have been 790,000 X-rays conducted in Tallaght hospital in the period we are discussing. If we were talking about making this issue known before the clinical review is conducted we would be trying to find out if the 790,000 people who had those X-rays were affected. The issue is that we conduct a clinical review in respect of those who were not signed off by radiologists and inform those people.

There are delayed diagnoses in two of the 37,000 or 38,000 cases that have already been reviewed. In that context, considering that the spectrum of risk in respect of error in radiology could be anything between 2% and 20%, that would indicate, as a general statement, and not taking away from the individual concern of any family that might be affected by this, that the cohort of X-rays relate to relatively low risk cases because there have been two out of a total of 38,000. Obviously, we have yet to have investigated precisely whether that delayed diagnosis affected outcomes, and that is something that will have to be dealt with clinically by qualified people.

In regard to the remainder that can be done by the end of May, if we were to proceed as has been proceeded with, and added resources have been provided since the chief executive officer came into the job on 15 December, what we are getting to then is a position where we will identify what will hopefully be a very low number and deal with those people specifically and be in a position to tell everyone else that they are not affected. The contention Deputy Kenny seems to be making is that by going about it in that way it was in some sense an attempt at a cover-up. It is not. It is an attempt to ensure that the focus is on the concern of patients——

Why did it happen?

——that those cases are dealt with, that the big backlog is looked into and the patients and the families notified. That was the concern.

A complete cover-up.

I do not accept the assertions the Deputy has made regarding the suggestion of non-accountability. The protocol sets out that we first identify if there is a need for the service to cease to ensure that any new patients are not affected and, second, identify if there are any patients who have been through the system who need to be followed up to have their care reviewed or amended. That is in the process of being done currently. Third, when the clinical needs of these patients have been met and they have been informed, we then proceed with carrying out an inquiry as to whether there are wider lessons to be learned and applied.

That is after the event.

Deputy Durkan, please.

Regarding the wider position, the director of clinical care has a programme head in respect of radiology, Professor Ó Laoide, the dean of the faculty of radiology and a foremost clinician in this area, and he will have to work with him in respect of issues that arise out of this but the first and primary focus is about those X-rays that are not cleared that must now be examined by radiologists, that are being examined by an increased number of people who have been put in for that purpose.

Nobody is to blame.

More than 3,000 per week are being examined——

Why were they not done at the time?

——and that is regarded by HIQA and others as an appropriate response to the issues being raised here that must be dealt with. I ask that in dealing with this matter and addressing the concerns the public may have that we do not make some of the assertions Deputy Kenny made because they are not founded on fact.

(Interruptions).

What about the other hospitals?

A Deputy

Ask Deputy Charlie O'Connor about it.

The Taoiseach should make a call to New Zealand.

A Deputy

Deputy O'Connor is very quiet.

The Taoiseach speaks about responsibility. There is only one responsibility at issue here and that is the responsibility to the people who went into Tallaght hospital to have an X-ray taken. As the Taoiseach said, there were more than 700,000 X-rays done in that period of time and I imagine that almost every one of those patients is worried about whether their X-ray was one of the 58,000 not examined by a radiologist. I understand 23,000 X-rays have not yet been reviewed. The first priority is to get those reviewed as quickly as possible and I want the Taoiseach to tell me how quickly that will be done.

Second, the people concerned who went in to that hospital for X-rays must be told whether there were X-rays included in these 58,000 that were not examined, given the all-clear if that is the case or told that there is a problem. That must be done as a matter of urgency.

The Taoiseach said this matter came to light in early 2009 and there is other information that it was coming to light in 2008. We are told general practitioners were making inquiries about this matter as far back as last summer yet it would appear that nothing was done about it until the new chief executive was appointed to the hospital in December when he found out about it. Having listened to his interview this morning, I presume somebody told him there was a big problem with X-rays that had not been examined by radiologists. He took some action to deal with it. What happened between the time somebody in the hospital found out that this was the practice and the time the new chief executive found out? Why was it not dealt with until the new chief executive was appointed?

The new chief executive says he told the Minister for Health and Children about the matter in December of last year but the Minister said this morning she did not really know the scale of the problem until yesterday. I find this unbelievable. Problems arose in Portlaoise hospital, Cork University Hospital and Ennis General Hospital and a number of reports were issued by HIQA. Over a period there has been a series of misdiagnoses and tests that were not followed through and the right people did not look at the files, etc. Questions must be asked if the chief executive of Tallaght hospital told the Minister for Health and Children that there was a big problem with X-rays and she did not even inquire as to the extent of it or make an inquiry.

Dr. Muiris Houston, in his article in The Irish Times this morning, states: “If such a significant failure can occur in one of the State’s premier teaching hospitals and not be addressed for over four years, it may well have happened in other hospitals also.” One would imagine that if the Minister for Health and Children was told in December by the new chief executive of Tallaght hospital that there was a big problem with X-rays, she would have inquired into how many X-rays were involved, how big the problem was and what needed to be done about it. She did not make such inquiries or inquire into how her Department or the HSE could help to resolve it and she told us she only found out about the full scale of the problem yesterday. After all we have heard before, that is just incredible. I find it difficult to understand why it did not dawn on the Minister that, if there was a problem of the size in question in Tallaght, there might be a problem somewhere else, thus meriting an investigation across the health service into whether there were other X-rays that were not being examined.

There is in Tallaght hospital a medical problem and a human problem for those involved. It needs to be addressed urgently and I urge that this be done. There is also a political problem. We have had enough and this country has had enough of the mismanagement of the health service. Nothing is done about the things that go wrong in the health service when they are discovered; they are only addressed when they become public. We are not hearing about inquiries and investigations and what went wrong. It is the same pattern all the time; it is only when a problem enters the public domain and becomes a public issue that there is a big flurry of activity. When reshuffling his Cabinet, will the Taoiseach appoint a new Minister for Health and Children?

Does the Taoiseach believe he will?

I have two points to make in reply to Deputy Gilmore. Portlaoise hospital was mentioned previously. I am acquainted with the issues that arise there. It was as a result of what happened in that hospital that a need arose to provide eight centres of excellence for the provision of cancer care and triple assessment. I recall the debate in this House on that issue. The record will show what was said. I heard very many people argue for the retention of status quo in a debate in this House, even in the aftermath of what had happened in Portlaoise.

Certainly none of us in here did.

I recall Members in various benches speaking about the need to maintain——

Some of the Taoiseach's backbenchers.

(Interruptions).

The Taoiseach, without interruption.

A Deputy

It was Deputy Devins.

I am making a point in respect of the Minister for Health and Children. I can name Members across the benches who——

The record will show it.

The point I want to make is that it was the Minister for Health and Children, with the support of the Government side, that brought about the changes that have resulted in real improvements for people with cancer care requirements, particularly those with breast cancer. This has been confirmed in recent weeks by a HIQA report. The support for the reform and change in facing up to the issue was not uniform in the House at the time in question.

Rather that criticising the Minister for being reactive, one should acknowledge she has been most proactive in trying to bring forward reforms in the health sector that are necessary and politically difficult and which do not always win support. When we see systems failures and difficulties in the health service, Members are quick to question in the House what is happening and the nature of the accountability mechanisms, and rightly so, but when people are involved in the reform of the health service and doing what is necessary to bring about better standards and greater cross-assessment and put clinical teams in place, there is very seldom the same uniformity of opinion.

That is not true.

The Taoiseach is talking about his own backbenchers.

It is true and the record will show it. Deputy Howlin was a Minister for Health, as was I, and he will note this has often occurred.

The Taoiseach left Tallaght hospital with a deficit of €8 million as Minister for Health and Children.

I have made a general point. To return to the specifics of the case——

Dr. McCutcheon resigned. The then Minister was in Angola.

——it was as a result of events in Portlaoise that we had to decide how to deal with a recurrence of such situations. One deals with them by trying to deal with the clinical needs of the patients concerned, as Deputy Gilmore said.

The clinical review in Tallaght hospital is being carried out. It is being conducted by qualified persons such as radiologists to deal with the backlog. I agree there will have to be an inquiry into why the backlog is so great. That will have to be dealt with as a wider issue.

That is the issue.

That must happen under the protocol after the clinical review is completed because, as Deputy Gilmore said, the important point is that patients be reassured in the first instance. The unfortunate problem we now face is that, because only two thirds of the cases have been clinically reviewed, one is not in a position at this stage to eliminate the vast majority of people who need have no fears in regard to the matter. As we have seen from the 38,000 cases that have already been reviewed, there was a delayed diagnosis in two.

People need to be reassured generally as to the level of risk involved. Deputy Kenny should note the level of risk is of a different nature from that which affected women in Portlaoise hospital in respect of symptomatic breast cancer. That is the position we are in.

To answer Deputy Gilmore's question, the HSE is engaging with Tallaght hospital today to see how we can expedite even further what has been achieved by the hospital thus far in dealing with the issue.

Why was that not done last December?

The facts can be collated in regard to matters before the period in question and we can do that through statements in the House if the Deputies wish. I am obviously setting out the facts available to me this morning. There has certainly been an acceleration in dealing with this issue under new management since mid-December. I am not in a position to say how much work was done prior to December although I understand some was done. I do not have the full information on this available to me this morning.

In New Zealand.

That is a cheap jibe from Deputy Quinn.

It is the usual cheap jibe from him and it ill-becomes him.

(Interruptions).

We are dealing with circumstances in respect of which I want to make sure the facts are available. I want to see what lessons will have to be learned in the hospital system in general but in the meantime the clinical review must be completed as a matter of urgency to provide some reassurance for worried patients.

The Taoiseach talks about the level of risk and seeks to give reassurance that it is low. The truth is that he does not know the level of risk. There are 14,000 patients who, over the past four years, had a total of 23,000 X-rays carried out at Tallaght hospital that were not examined by a radiologist. Those X-rays have not yet been reviewed. Therefore, the Taoiseach does not know the risk.

How quickly will the X-rays be reviewed? How quickly will the individuals concerned be reassured if, as I hope, that is to be the outcome? Addressing these questions is the first priority. We need to have some information. If the Taoiseach cannot provide it now on Leaders' Questions and the Minister for Health and Children is in New Zealand, somebody from the Government needs to tell us the story today and state how quickly the 14,000 cases will be dealt with.

Second, the Taoiseach did not answer the question about when the patients will be told. To the best of my knowledge, none of the patients involved has yet been told that he or she is involved and given full information on the position in regard to his or her X-rays. Third, the Taoiseach did not answer the question as to what happened in the period between when this issue first came to light and when the new chief executive officer found out about it. It seems nothing was done in that period, and there must be some explanation of why that was so.

Fourth, the Taoiseach has not answered the question as to why the Minister for Health and Children seemed not to take the matter terribly seriously when she was told about it. She tells us on the radio this morning that she did not know the full extent of it until yesterday and that she relied on the protocols and so on that are in place. If the Minister for Health and Children was told by the new chief executive officer of a hospital that there was a problem — and told it at a time when the Minister has been in and out of this House and involved in public controversy about misdiagnoses and problems associated with tests not being looked at and so on — I do not understand why she did not go on alert. What did she do between the time she was told about it in December and now when it has come into the public domain?

Finally, does the Taoiseach intend to leave the Minister, Deputy Harney, in her Ministry or will he replace her? He is apparently considering a reshuffle of his Cabinet. Some time ago my party tabled a motion of no confidence in the Minister arising from some of these earlier incidents. I have a lot of time for the Minister — she has been a very competent Minister in other ways — but she has been a hopeless Minister for Health and Children and it is time she was moved.

That is not true.

When I talk to people about the state of the health service, one of the questions that comes up repeatedly is how long the Taoiseach intends to leave the Minister, Deputy Harney, in charge of the health service. He is about to reshuffle his Cabinet and has an opportunity to tell the people of this country this morning whether he will appoint a new Minister for Health and Children next week, the week after St. Patrick's Day or whenever it is that he will come into the House and announce a reshuffle.

I am not going to go down that road other than to say the Minister, Deputy Harney, has my confidence. She has been a reforming Minister for Health and Children and has brought about more changes for the reform of the health sector than any of her predecessors. She has been absolutely committed to bringing forward quality assurance mechanisms in the system so that we have accountability and can deal with any issues that arise. The response of the Health Information and Quality Authority to the problems recently highlighted in respect of children in care was a result of the accountability mechanisms in place.

Having accountability mechanisms is not about presupposing that the system is and will be perfect in every instance and on every day of the week. In a modern health system hundreds of thousands of clinical decisions are made every year. Nowhere in the world is it suggested that such a system is error free. We must make sure that we identify where errors arise, that we mitigate the problem——

There is no responsibility.

——and that we try to eliminate risks.

That was not done.

The Taoiseach must be allowed to speak without interruption.

Clinical decisions are made by people and are subject to human error. I am speaking generally and not specifically about this case, to which I will return.

It came to light in December and was not dealt with.

The idea that there is a prospect of having a system that works perfectly in every respect is not correct. It is about making sure that we have a system that is accountable, which identifies issues as they arise, deals with them and ensures lessons are learned from them. It is about ensuring best practice models are put in place across the system.

The great problem of the health system before we began to modernise and reform it was that the hospital system was a stand-alone system rather than a network of facilities that pulled together the various specialties in a way that allowed people access to the best possible health care by ensuring the resource was properly planned and configured. That process is ongoing. There has been a greater degree of change in that respect, which has been much to the benefit of the health system and the people who use it, under the Minister, Deputy Harney, than anyone else. I will stand over that. Labour Party Members can scoff as much as they wish but the objective facts will show the improvements for patients since we brought in changes. Those changes are ongoing and more needs to be done in respect of further redeployment, in respect of the move from a hospital-based system to a more community-based system, in driving forward primary care centres throughout the State, in putting in place primary care teams in communities, and in respect of an entire range of structural changes that are fundamental to a modern, sustainable health system that will provide the best possible care rather than assuaging every parochial interest that seems to raise its head in respect of the health system.

(Interruptions).

Members must allow the Taoiseach without interruption.

That is the first point.

Will the Taoiseach answer the question?

I have answered Deputy Gilmore in respect of that aspect of his question.

The Taoiseach has not answered the question.

On the next aspect of his question, what happened is that the Minister, Deputy Harney, met with the chief executive officer of Tallaght hospital, who had been appointed to that post the previous day, and others in regard to an issue about the Coombe Hospital and how it would be dealt with in terms of how that hospital would be involved with Tallaght hospital in the future. At the end of that meeting the Minister wished the chief executive officer, who was previously medical director at the hospital, well in his post. He mentioned that there was an issue in the radiology department which he intended to get to the bottom of and deal with. Professor Conlon has the Minister's confidence and he proceeded with putting in place measures, in line with the protocols that were established post-Portlaoise, to deal with the background that had been identified in the radiology department. Nothing has been done since that would not have been done or should not have been done.

The Health Information and Quality Authority accepts that the response in the hospital to the backlog is appropriate and that the numbers of X-rays being read — of the order of 3,000 to 4,000 per week — by the extra consultant radiologists who have been employed there is exceptional and appropriate. To answer the Deputy's question directly, if the present rate of progress continues, it is expected to have this process completed by May 2010. In the meantime, as a result of this matter now coming into the public domain in the way it has, and before the clinical review has been completed, HIQA is having a discussion today with Tallaght hospital management to see how the process can be further accelerated if possible in an effort to assuage people's concerns.

Why did the backlog occur in the first place?

In regard to the question of the level of risk, I am simply making the point that statistically, based on what we have seen thus far, the fact that there has been a delayed diagnosis in just two of the 38,000 cases is an indication — not a confirmation but an indicative, statistical indication — that we are dealing with relatively low risk. In regard to the remaining 23,000 that have yet to be looked at, I understand from this morning's interview with the manager of the hospital, Professor Conlon, that 10,000 of those relate to orthopaedic issues which could have emerged from fracture clinics or wherever. All of those x-rays would have been looked at by the clinician dealing with the patient. What we are talking about here is a procedure for best practice where those X-rays, having been looked at by the clinician and the patient dealt with accordingly, would have been referred to the radiology department. Best practice is that the radiologist would look at the X-ray and write a note which in most cases would confirm what was looked at by, in the case of a fracture clinic, the orthopaedic surgeon.

What has happened is that in the case of X-rays which were looked at by the clinician dealing with the patient and then referred to the radiology department, six out of 100 of those since 2005 have formed part of a backlog. That is the investigation that has to take place after we have dealt with the clinical review that is not yet completed. That is best practice for dealing with this type of issue.

The Minister was asleep on the job.

The problem is, as the Deputy observed, that there are people very worried about what has happened. A helpline has been established to deal with concerns people may raise. The ideal situation would be to allow the clinical review to be completed, and we will see whether that can be accelerated. I am trying to put the issue in context and to convey to people in a responsible way what one can best say is the level of risk involved in this in order that people, however concerned they can rightly be, are not unduly concerned or unduly put under an anxiety that may not be justified by the circumstances of their case. I am indicating, that of the 38,000 already looked at, two have resulted in a delayed diagnosis. We have yet to see whether outcomes were affected because of the delay in diagnosis, rather than because there is any question of a misdiagnosis.

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