Dáil Éireann debate -
Thursday, 10 Oct 2013

Vol. 816 No. 3

Leaders' Questions

Deputy Billy Kelleher

I express my deepest sympathies to the family of Savita Halappanavar and her husband, Praveen, as the anniversary of her tragic death on 28 October 2012 approaches. The report published by the Health Information and Quality Authority, HIQA, into the circumstances of Ms Halappanavar's death makes difficult reading for her family and many others, especially women and those involved in the provision of front-line maternity care services.

Last year, the Health Service Executive in Galway gave an assurance that an implementation plan would be put in place to ensure maternity services would be monitored and failings addressed. The bigger issue, however, is maternity services at national level. For example, the HIQA report highlights deficiencies in the implementation of guidelines in the area of sepsis. Another key issue highlighted is a lack of resources which is creating significant pressure on the delivery of front-line maternity services. The issue has also been raised by the masters of the Rotunda and Holles Street maternity hospitals and other obstetricians. As I have stated in previous discussions of this issue, this is not a political point but a matter of ensuring that women have absolute confidence in our maternity services.

What is now required is the immediate establishment of an implementation body to assess and review the Health Service Executive's commitments to implement the plans it has outlined. More important, the HIQA report on the death of Savita Halappanavar and other matters must be implemented in full. Will the Tánaiste give a commitment to hold a full, independent review and audit of maternity services, including the staffing and resourcing of same, and to ensure that any deficiencies highlighted in such an audit will be made public as quickly as possible?

One area on which immediate action could be taken is front-line maternity care services, which have been shown definitively to be under significant pressure. There is a shortage of midwives, maternity hospitals are under-resourced and we have a low ratio of obstetricians to population. With 70,000 births each year in this country, we should have many more obstetricians. Will the Tánaiste give a commitment to act on the recommendations of the report? Will he also undertake to lift the embargo or moratorium on the recruitment of front-line staff for maternity services?

The Tánaiste

I join Deputy Kelleher in expressing again my sympathy and that of the Government to Praveen Halappanavar and his family on the death last year of his wife, Savita. The report published yesterday makes difficult reading for them and everybody with an interest in maternity services. I do not believe there is a woman in the country who does not put herself in that bed on St. Monica's ward and I do not believe there is a man in the country who does not see his wife, partner or daughter in that bed or ask himself very basic questions about it.

I have read the HIQA report and it does what the authority was asked to do, namely, to get to the bottom of what happened in Galway and why and to establish what lessons can be learned from it. As with all such reports, this report is written in careful language. Reading through it, however, a number of things become very clear. It correctly makes the point that everybody is entitled to be safe in our hospitals and to receive the best quality of care. It notes a general lack of provision of basic fundamental care, for example, failure to follow up on blood tests, failure to recognise that Savita Halappanavar was at risk of clinical deterioration and failure to act or escalate concerns to an appropriately qualified clinician when Savita Halappanavar was showing signs of clinical deterioration, and refers to ultimate clinical accountability resting with the consultation obstetrician who was leading the case. When one reads these points, one must ask fundamental questions about whether someone was not doing his or her job or not doing it properly.

The recommendations refer to governance failures, stating, for example, that the "clinical governance arrangements within the Hospital failed to recognise that vital Hospital policies were not in use nor were arrangements in place to ensure the provision of basic patient care on St Monica's Ward". When one reads this statement, one must ask fundamental questions about the management and supervision of the service. When one reads about the length of time clinicians were spending at committee meetings, one must ask basic questions about how the Health Service Executive is governed and run. When one reads the recommendations addressed to the HSE and Department and Health, one must ask basic questions about how maternity services are provided. When one reads, for example, that five of the 19 maternity hospitals had not delivered on a previous report, one must ask fundamental questions about the delivery of a national maternity strategy in this case.

This is a very good report which contains recommendations that are addressed right across the board, from the hospital ward to the desk of the Minister for Health. These recommendations will be implemented. What we must do, and what Savita Halappanavar and the women of this country are owed, is to implement the recommendations with urgency and put in place systems, supervision and co-ordination to ensure we do not have another Savita Halappanavar case and the women of this country receive the maternity care and care in pregnancy to which they are entitled. This is what the Government and Minister for Health will address. While I am open to audits, independent examinations or other measures if they help to achieve or oversee this process and ensure it is completed, let us not go down the road of having another audit or report. We have a very good report; let us get on with doing what it asks us to do by implementing its recommendations.

Deputy Billy Kelleher

I thank the Tánaiste for his reply. Unfortunately, we had the very tragic case of Tania McCabe in Drogheda who died in 2007. At that time national guidelines were drawn up with regard to sepsis. Only five of the 19 maternity hospitals are currently implementing those guidelines as has been highlighted in this report. We then had the tragic case in Galway. While the Tánaiste talks about governance structures and local management, the report also consistently refers to the Department of Health so it is not just an issue of pointing to local managements and saying they must do better. Of course they must do better but they must also be resourced. The report is clear and definitive in pointing out that resourcing is a key issue in ensuring the safety of maternity services. While it refers to governance and accountability, the key point is that resourcing is paramount in the delivery of maternity services.

The Tánaiste also said that following the tragic death of Savita Halappanavar, we do not need another audit. However, we need to insist and ensure this report is implemented in full. We have had a previous report and only five of the 19 maternity hospitals implemented its recommendations. What commitment can the Tánaiste give today to ensure that at some stage in the future every recommendation in the report will be implemented in full? While it states that the HSE must implement, it also states that the Department of Health must implement. That does not exonerate political people; it puts political people directly responsible for the implementation of the report. That includes all facets, including resources.

An Leas-Cheann Comhairle

Thank you, Deputy.

Deputy Billy Kelleher

We cannot have the report implemented in theory but not resource maternity units throughout the country.

The Tánaiste

There should be no issue of exoneration at any level regarding this issue. This is not a time for anybody to be exonerating themselves. I have been through the report which is very good and detailed, albeit using some of the guarded language that these reports use. I believe it gets to the nub of where the problems are. At every level actions need to be taken to address what is in this report and to implement its recommendations.

As the Deputy has said, there was a previous case in 2007 and there was to be follow-up on that. The report states:

The HSE reported that these recommendations were implemented at a local HSE level with regional HSE oversight. On enquiry, the Authority noted with concern that only five of the 19 maternity hospitals/units were able to provide a detailed status update on the implementation of recommendations from the Tania McCabe report.

Referring to what happened in Galway the HIQA report states:

The Hospital reported that 167 maternity and non-maternity patients in total required ICU care as a result of sepsis in 2011 and 139 patients in 2012... the Authority [HIQA] found that at the time of the investigation, the Hospital did not have a hospital-wide guideline in place for the management of sepsis in adult patients.

We need to ask why that was. That issue needs to be addressed. The HIQA report also states:

The Hospital had a guideline in place for the management of ‘Suspected sepsis and sepsis in obstetric care’. However, the clinical governance arrangements were not robust enough to ensure adherence to this guideline.

What does that mean in plain language? Does it mean somebody was not implementing or enforcing those guidelines or does it mean there was an attempt to enforce them and they were not complied with? That needs to be addressed. We need to take this report in its totality. It does not spare any level of the health service, from the ward to the Minister's office. I believe it needs to be taken seriously. It needs to be answered and addressed, and its recommendations need to be fully implemented.

Deputy Mary Lou McDonald

The Tánaiste has said the report makes for difficult reading - for nobody more than for the Halappanavar family, the family of Tania McCabe, for many other families and for any woman, particularly any woman of child-bearing age who may at some stage rely on the maternity services in the State. The Tánaiste described the report as a good report; I would describe it as a damning report. As he has acknowledged, it registers failures in the most basic elements of medical care that Savita Halappanavar had every right to expect, including, very disturbingly, an absolute failure to recognise the vast deterioration in her health. The mind boggles at that prospect.

The criticisms, as the Tánaiste has acknowledged, are not simply restricted to St. Monica's ward. His language has been very evocative and no doubt we can all imagine the scenario for Savita Halappanavar and the turn of events for her and her husband, Praveen, over those fateful days. Of course the implications of the report go far beyond that ward. We now see a mirror held up to our maternity services, showing us clearly that the vital safeguards, and the most basic provisions in terms of good governance and good practice in our maternity services, simply are not there. The authors of the report found it impossible to provide assurances that women are receiving safe or reliable care during or after pregnancy.

I agree with the Tánaiste in saying that questions arise from the report. There are questions around accountability in the case of the particular hospital in Galway, and in respect of local and regional HSE authorities. A question of negligence or malpractice arises. If that is not stated openly, it is certainly implicit in the report's content. Not alone are questions raised by this report, but answers are demanded. The implication of this report moves from St. Monica's ward through the HSE to the desk of the Minister for Health and then it lands fairly and squarely on the desk of the Cabinet. The questions people want answered are as follows. How will the accountability, of which the Tánaiste speaks, be delivered? We have mentioned the previous case of Tania McCabe in 2007. At that time guidelines were drawn up and we all resolved that we would have learned the lessons. Six years later those recommendations have not been implemented.

An Leas-Cheann Comhairle

Thank you, Deputy.

Deputy Mary Lou McDonald

We have another tragic turn of events and the same sort of event unfolds again. That is not accountability; that is a matter of farce - a very dangerous farce for women's health. What about the accountability and, crucially, what about the resources?

An Leas-Cheann Comhairle

Thank you, Deputy.

Deputy Mary Lou McDonald

Next Tuesday is budget day when decisions on spending will be made, including in the area of health. What comfort and reassurance can the Tánaiste give to women, who are potential users of the maternity services, that the issue of lack of resources, identified fairly and squarely by HSE spokespersons as recently as this morning, will be addressed?

The Tánaiste

One thing here matters above any other consideration of political debate or different interests in the health service lifting chunks of this report perhaps to support or defend a case that they are making.

Over and above any of that has to be safety for the patient and for women who are admitted to our hospitals during pregnancy. In this particular case, the report stated there were 13 possible interventions that could have been made and which did not happen in the period when Savita Halappanavar was in hospital.

Resources are always an issue; of course they are. However, I do not believe anyone who reads the report could say that resources were the issue in respect of all 13 of the possible interventions that could have taken place. The report in the Tania McCabe case was implemented in five out of the 19 hospitals. That raises the question of why was it implemented in those five but not fully in the others, although it appears to have been partially implemented in some of the others. That must be looked at.

This is a collective thing. As I said earlier, what we have to do is take this report, resolve that this should never happen again and do what is necessary to make sure of that. That means implementing the recommendations in the report. For example, one of the issues raised in the report in terms of the deployment of our resources was whether we should continue to have 19 maternity hospitals or units in the country. That is an issue for all of us because, let us suppose, for example, the Minister for Health came to the House and said that he wanted to rationalise the number of maternity units or wards and have a smaller number of better equipped, better quality and better standard maternity hospitals. Let us ask ourselves in all honesty what the response to that would be.

I put it to every Member that I believe this is a good report. The recommendations in it are very strong and they should be implemented. Responsibility for the implementation of those recommendations primarily rests with the Minister for Health, the HSE management and so on. There may also be issues of choice, general policy and the deployment of resources that will ultimately be issues for everyone in the House. When we come to address those issues, we should do so with the best interests of the patient and of women at heart.

Deputy Mary Lou McDonald

When "never again" is said on this occasion, it needs to mean never again. I suggest to the Tánaiste that this means that he ought to ask the Minister for Health, Deputy James Reilly, to explain to him, the Cabinet and to those of us in the Chamber how it is that only five out of 19 maternity facilities introduced the guidelines. We want to know why that is the case and the public ought to know why that is the case.

The Tánaiste referred to the issue of resources. I hope the Tánaiste will not use this report or the tragic turn of events for Savita or Tania McCabe as some kind of pretext to cut back on maternity services. The Tánaiste is right. We have to make decisions about how we arrive at the safety that we all require. I agree with him entirely. However, I put it to the Tánaiste, and I know from experience, that for a heavily pregnant woman, the prospect of having to travel hundreds of kilometres to get to a maternity service or hospital would not be a helpful or a terribly safe thing for her to do.

Deputy Finian McGrath

There is the rationalisation.

Deputy Mary Lou McDonald

This morning, not only the HSE spokesperson but the masters of the maternity hospitals have been saying that they are struggling to cope with the level of births and the level of services they must provide in our maternity hospitals. We all know it and they have been saying it for a very long time.

The report identifies failures in management and accountability, including political failures, but it also raises the question of resources. I suggest to the Tánaiste that if "never again" is really to mean never again, we need to resolve the accountability and governance issues, including the role of the Cabinet and of the Minister for Health. We must also be truthful about the resources that are required in our maternity hospitals. Anyone who visits the Rotunda, the Coombe or Holles Street can see the bedlam at play at times in those fine facilities. One is left in no doubt that there is an acute resource issue on the front line. I say as much to the Tánaiste, not to let anyone off the hook in respect of the lack of treatment and appropriate care for Savita Halappanavar - I am keen to emphasise that point - but simply to state that if we are serious about the safety of women and their babies and a quality maternity care service, we must have a resourced front line. On Tuesday, the Government will have an opportunity to ensure that is the case.

Will the Tánaiste be more specific about the implementation of these recommendations? Does he intend to speak or has he spoken to the Minister for Health, Deputy Reilly? Will the Tánaiste ask the Minister for Health to come before the House without delay to set out his response to the report and the failure of hospitals throughout the State to implement the recommendations many years on? Will the Tánaiste give a commitment to the women of the country that he will ensure the necessary resources are at the front line, where women and their babies need them?

The Tánaiste

We have a choice with this report. We can take it now and use it as ammunition in whatever case we want to make, whether a political case around the budget or the delivery of resources, a case in the arguments that go on within the service about whether resources should go here or there, or in arguments between one institution and another. We can use it in those ways or we can take this report, as I do, in its totality and say that actions need to be taken at every level. We should not pick one and use it simply to go there or to make this or another argument. We should take the report in its totality, take the entire set of recommendations and determine that we are going to have them implemented. As I have said, there are implications in the report for people at every level in the health service, every level of government, every level of management and every level of delivery of service in the maternity services. The report needs to be implemented in its totality.

There are issues of resources. Of course there are; there always are. There are issues of the management and quality of the maternity services that have to be addressed. However, the report is very clear that there are also other issues. This report relates to a particular case, a particular institution, a particular service and one very tragic, awful case. There are implications in it for how the job is actually done, how the service is actually delivered in the ward and what actually happens when something goes wrong. This report is shocking in terms of what actually happened in the ward in this particular case. The report is also clear about where action needs to be taken and the paths that need to be followed in respect of taking action in the matter.

I do not believe it serves the health service in its totality well or the people who work in it, who deliver a high quality service and who work hard, diligently and professionally every day to ignore those aspects of the report. No aspect of this report should be ignored, including those which land at the headquarters of the HSE or the desk of the Minister for Health. They should not be ignored either.

As I believe there must be accountability both for what happened and for the implementation of the recommendation in these reports, I suggest the health committee of the House ask the relevant people, who have questions to answer arising from this report, to appear before it. In the first instance, they should do so to address specific questions that arise from the report and over time, to address the implementation of its recommendations.

Ireland has a public accountability system. That is how public accountability is delivered for the people who pay their taxes for the health service, those who depend on it and those who must access hospitals and who, as Deputy McDonald noted, in some cases travel long distances to get particular care in hospitals. This should be done. I do not believe this report should be let rest or let lie but there should be a resolve at every level to deal with its recommendations and implement them.

Deputy Seamus Healy

The Government has cut heating supports, such as the fuel scheme and the free units of electricity, in each of the last three years. In 2011, the number of free electricity units was reduced from 2,400 to 1,800. In 2012, the period over which the fuel scheme operated was cut by six weeks and in 2013, the household benefits package, including the free units of electricity, was cut again. Even before these cuts were implemented, it is known there were more than 1,000 additional winter deaths in the Republic. Moreover, it is known the vast majority of such deaths were due to cold-related conditions and that such conditions exacerbated underlying medical conditions such as, for instance, respiratory illnesses. These facts are known on foot of professional research carried out and directed by Professor Goodman of the Dublin Institute of Technology. This research was peer reviewed and publicly funded through the Centre for Ageing Research and Development in Ireland and was launched by the Tánaiste's colleague, the Minister for Communications, Energy and Natural Resources, Deputy Rabbitte. It is known that before the cuts introduced by the Government, heating costs were significantly cheaper. Over the past three years, gas costs have increased by 22%, 8.5% and 2% in 2011, 2012 and 2013, respectively, giving a total increase of 32.5%. Similarly, the cost of electricity rose by 14.8%, 5.9% and 3.5% in 2011, 2012 and 2013, respectively, giving a total increase of 24.2%. In addition, the cost of oil rose by 18% in 2012 alone.

A recent press release from the Society of St. Vincent de Paul reveals that the increase in energy bills over the past three years has cost €500 per family. This wipes out completely the value of the fuel scheme for 2013-14. The Society of St. Vincent de Paul also revealed that it now spends more than €10 million per annum to provide heating supports for needy families.

An Leas-Cheann Comhairle

A question please, Deputy.

Deputy Seamus Healy

Is the Government monitoring the increase in winter deaths due to cold-related conditions caused by the Government cutbacks to heating supports? Does the Tánaiste know how many deaths the cuts relating to heating supports have caused since 2011? Will the Government reverse these huge cuts to needy elderly families?

Deputy Finian McGrath

Hear, hear.

The Tánaiste

The Government is very much aware of the increase in the costs of fuel and the pressure that is putting on households, families and elderly people. This is the reason a range of supports is in place to support people with the cost of fuel. One thing that is clear regarding fuel, energy and gas is that we in Ireland are receivers. We are receivers with regard to the cost of fossil-based fuels, including oil and gas, and are very open to the way in which the price of such commodities fluctuates on the world market. This is the reason the Government is doing two things on a strategic level. First, it is increasing the generation of renewable energy in Ireland to reduce our dependence on oil and gas and to enable the supply of electricity and energy at a lower cost. Second, the Government is addressing the retrofitting of homes in order that their energy efficiency is improved and the cost of heating them is reduced. Thus far, approximately 250,000 homes have been retrofitted. The Government is particularly concerned that the retrofit scheme would proceed for those households with low incomes. A total of €50 million has been provided to improve the insulation of 25,000 of the least energy efficient homes over a three-year period and 1,000 of these improvements have already been carried out. Additional funding has been provided to address the retrofitting of local authority-owned homes to improve their energy efficiency.

This issue must be considered in two ways. First, the support the Government provides for households through the fuel allowance, for example, must be maintained. In addition, the issue must be addressed at the level of the energy efficiency of the home itself. This is the reason the retrofitting of houses to get higher standards of energy efficiency and thereby reducing the cost of heating the home must be part of what must be done. Ultimately, that is the best way of doing this sustainably over a longer period.

Deputy Seamus Healy

As usual, the Tánaiste has not answered any question I asked of him.

Deputy Finian McGrath

Yes, it is disgraceful.

Deputy Seamus Healy

It is the usual performance in this Chamber and sometimes one wonders whether it is worthwhile to ask any question. The Tánaiste naturally blames the world markets for the increases in prices and while that is well and good, the Government's response to increased costs has been to cut supports to needy families by cutting the fuel allowance, the free units of electricity and the household packages. The Government has deliberately and knowingly cut heating supports. It is known that cold-related conditions mean additional winter deaths. This policy is an act of social vandalism and is a matter of life and death. Must Members wait until there are more elderly deaths before finding out what is the exact position? Will the Tánaiste answer my question now? As the Tánaiste does not know the answer, will he ask the Central Statistics Office, for instance, together with the Centre for Ageing Research and Development in Ireland, to ascertain how many deaths the Government's cuts have caused since it came to power in 2011? I again ask the Tánaiste whether the Government will reverse the huge cuts that have taken place over the past three years and for which it is responsible.

Deputy Finian McGrath

Hear, hear.

The Tánaiste

There are occasions in this House when allegations are made that are seriously over the top.

Deputy Seamus Healy

Like?

The Tánaiste

The allegation the Deputy has made in this particular case falls into that category.

Deputy Seamus Healy

Which allegation?

The Tánaiste

No, let us concentrate on dealing with the problem.

Deputy Finian McGrath

The Tánaiste did not answer the question.

The Tánaiste

The issue of fuel costs is a matter of which the Government is aware-----

Deputy Michael Healy-Rae

The Government has made it more expensive.

The Tánaiste

-----and which it is seeking to address.

I have set out for the Deputy the way in which we are seeking to do that.

Deputy Seamus Healy

By cutting the supports.

The Tánaiste

The Deputy has asked me to ask the Central Statistics Office to produce figures for us. We will do that and I have no problem with that. We will ask for advice from anybody who has advice to offer to us in this area. We will listen to what any of the organisations representing older people in this country have to say. We will take advice from wherever we can get it, but there is a difference between hearing that advice, addressing it in a reasonable way and making the kind of over the top hyperbole that the Deputy has just made.

Deputy Seamus Healy

Which one?

The Tánaiste

The Deputy asked whether we would ask the CSO to produce figures for us. The answer to the Deputy's question - let me be clear on this because he accused me of not answering his question - is: "Yes, we will."

Deputy Seamus Healy

What about my second question? I asked whether the Government will reverse the cuts, but the Tánaiste did not answer that one.