Ceisteanna ó Cheannairí - Leaders' Questions

We have fantastic people working in our health service and the outcomes for those who access it are generally very positive. The year 2018, however, has been marked by a number of incredibly tragic incidents that are still ongoing.

We had CervicalCheck and the implications of that. Deputy Alan Kelly hosted a very powerful meeting last night around some of the women affected there. We had the issue that I raised with the Tánaiste in November, highlighted by Mr. Justice Peter Kelly about non-qualified doctors in our hospitals.

Yesterday we had the report from the analysis of the scans at University Hospital Kerry. That found that 11 patients, one of whom has passed away, suffered delayed diagnosis. That person waited for 76 weeks, 18 months, for a diagnosis of lung cancer. A total of 44,831 X-rays were audited and found to be correct. That is an important figure to remember. A figure of 1,298 X-rays had significant errors, and 420 patients had to be recalled and, of those, some 59 required further tests. According to the report, these X-rays and the scans were read by a locum consultant who no longer works in the hospital, having resigned from it in October 2017. Can the Tánaiste confirm that that person is not working in the Irish health service at the moment?

On the broader issue, there are currently more than 500 consultant positions filled by non-consultants. They are either locum, fixed-term or specified-purpose contracts. That represents 16% of the total population of consultants. There are further 199 unapproved posts. We have vacancies at therapist level, nurse level and GP level right across the health service. It is straining under the pressure of work, which is being exacerbated by these vacancies. A key recommendation of the report yesterday was that we would define acceptable volumes of work for individual radiologists. That is surely a concept that can be extended right across the health service. How does one define "acceptable volume of work" for anybody in the health service when there are such vacancies and such demand? The Government is continuing to put its head in the sand about the impact of those vacancies on patient care, and on people working in the service and the pressure those vacancies are putting on already pressurised work environments.

Does the Tánaiste accept that the vacancies across our health service are unacceptable? Does he accept that the vacancies are allowing doctors who are not qualified to work in positions that they should not be in? Is he concerned about the impact these vacancies are having on the quality of care available and the impact that these are having on morale among those working within the health service?

I thank the Ceann Comhairle. The Deputy has a lot of questions there.

First, I wish to express my heartfelt sympathies to the patients and families involved in the recent case and the report that was published this week. I acknowledge that this was a time of real uncertainty for many patients and their families. I appeal for confidentiality to be respected for the families concerned.

It is important to note that the aim of this look-back review has always been to ensure patient safety, to identify whether any clinically significant radiological findings had been missed and to ensure that those identified were managed correctly in the interests of patients, with patients being communicated with appropriately and at the right time. Throughout the review process the HSE has had a comprehensive communications process, including provision for open disclosure and dedicated clinical co-ordinators to liaise with patients and GPs. This included a freephone helpline and a dedicated website. I have been advised that all patients have now received follow-up and care, as needed, and have been provided with support from the South/Southwest Hospital Group. The report of this process provides assurances that the issues have been examined appropriately from a clinical perspective. In its report the serious incident management team, SIMT, has made a total of 16 recommendations and the HSE has confirmed that the implementation of the recommendations of the report is already well under way.

Legal proceedings have been issued in three cases and they will be managed by the State Claims Agency.

All imaging related to one individual consultant radiologist between 24 March 2016 and 27 July 2017 were reviewed. The HSE has advised the scope agreed for the review was focused solely on University Hospital Kerry. The consultant radiologist was placed on administrative leave pending a full review and has since resigned their position. The Irish Medical Council was notified of the concerns in relation to poor professional performance by this doctor in October 2017 and its assessment is still under way.

The total number of patients identified during the review with missed or delayed diagnosis is 11. Four of the patients identified with either missed or delayed diagnosis have now passed away. Of the 11 patients, eight had either re-presented to the health service or their diagnosis was made by the normal multi-disciplinary review. These patients had been diagnosed by the time of the look-back review. A further three, however, were found during the look-back review process and diagnosed thereafter as a result. Following repeat imaging during the recall, 59 patients were identified as requiring further clinical follow-up and-or investigation. Ten further patients have been referred to other hospitals for specialist care.

Four families have lost their loved ones because of this and we do not know how many more of the other seven may be affected. I join in the expressions of sympathy but it is not good enough. We do this every time we have an incident, and that sympathy is heartfelt but we do not learn from it. We need to learn that this must not happen again in another hospital. We need to have some sort of patient focus at the heart of Government that actually says we will not continue to come into this Chamber every few months offering sympathy. We need action. I have identified the recommendations from the report on what are determined to be acceptable workloads. Is that something the Government will take on board and implement across the health service at all grades? Will it give health professionals workloads that they can manage, the support they need to do their job and take a proactive role in filling the vacancies at every level? The Government cannot keep putting its head in the sand about our consultant, GP and nurse vacancies. We need proactivity to fill those vacancies to take the pressure off our health professionals and to avoid a situation where we come back to another expression of sympathy.

Finally, I repeat my question - is the person involved in this case still working in the health service?

I do not disagree with anything the Deputy has said. We need action and action is taking place. The whole point of this look-back review was patient-centred. It was to expose failings if they were there and how they happened to ensure that they would not happen in the future. There are 16 recommendations and they are already being implemented in some cases, and they all will be implemented. Yes, there are vacancies across our health system and the HSE and the Department of Health are working to ensure that those vacancies are addressed.

There has been a significant increase in the number of nurses in the healthcare system in the past 12 months. There have also been increases in the numbers of consultant doctors. Therefore, all of the actions for which the Deputy is calling are under way. I agree with him that it is simply not good enough, but all the same, it needs to be said that what families expect and want when their loved ones go into hospital is that they receive the highest quality of care and that if mistakes are made, they will be exposed quickly through the systems that pick them up and that we learn lessons from them in order that they are less likely to be repeated in the future. That is what is happening in this case.

I also want to refer to the review published yesterday by the HSE of the 46,000 radiology scans carried out at University Hospital Kerry in Tralee. The report has found that 11 patients had their diagnosis of cancer delayed and that four of them have since passed away. Some of the 11 patients received the report by taxi, which is not an appropriate or patient-centred way to deliver a report to any victim. Our thoughts are with the families, in particular, at this very difficult time and all those affected by the scandal. While I welcome the publication of the report, there are a number of outstanding issues on which we require clarification which I hope the Tánaiste will be in a position to provide.

First, less than two pages of the report deal with recommendations to prevent a similar situation from arising in the future. When asked yesterday by my colleague, Councillor Toiréasa Ferris, what was the timescale for implementation of the recommendations, hospital management could not give her an answer. Unless management accept its failings and responsibilities and puts measures in place to address what happened, it can and could happen again. The concerns about misdiagnoses and hospital scans were being raised by hospital staff and GPs and it seems that the appropriate action was not taken until a later stage. Therefore, I want to know what are the HSE and the Minister going to do about it? Will a timeline for implementation of the recommendations be produced and will it be published?

The matter of most concern is that, over a year after the issue first came to light, not only are guidelines on the volume of work radiologists should be undertaking not in place but the process to develop them does not seem to have even started. What specifically is being done about this and will the guidelines be produced without delay? That is absolutely crucial because the workload of the consultant in question was a key contributory factor in patients receiving a misdiagnosis or there being a delayed diagnosis. That issue needs to be addressed urgently.

The report acknowledges that four people died as a result of receiving a misdiagnosis or there being a delayed diagnosis, but there is a fifth person whose family believe she passed away as a result of the same factor. She had been told that her case was part of the review in February, but she heard nothing after that point. Unfortunately, she has since passed away. Will the Tánaiste give an assurance that the hospital will engage with her family in order that they can receives the answers they are so desperately seeking?

There is a real possibility that people may have to go through the courts to get justice in what clearly are cases of medical negligence. We already know that one application has been lodged. Will the Tánaiste give us an assurance that that will not happen and that the hospital and the HSE will engage with victims and families to ensure they do not have to through the rigmarole of the convoluted legal process to get justice? In some cases people are terminally ill. The issue is time sensitive and we need to ensure action will be taken immediately, something which has not happened heretofore.

The report was only published in the past 48 hours. It contains 16 recommendations and my understanding is they are being implemented. Tragically, four people have passed away since the review began. I do not know the circumstances of each individual case. Therefore, in the circumstances we should be careful about what we say in apportioning blame. Families who still have questions to ask and need answers need to receive the full co-operation of the hospital and the HSE. The review was triggered by complaints which led to concerns about the quality of care patients were receiving in the hospital. As a result, all of the scans and workload linked with one consultant doctor were re-examined, from which we have learned lessons which raise serious questions which need responses.

I do not have the guidelines on the workload of radiologists in front of me, but I expect that there would not be a problem with making them available. It is the job of the HSE and hospital management to make sure they have teams available that can work in a way that is consistent with medical guidelines. If there are a family or an individual to whom the Deputy is referring with particular concerns, I do not have their details, but if the Deputy makes them available, I will certainly ensure the Minister's office is made aware of them. We are trying to ensure the response will be patient-centred, that lessons will be learned, that systems will be put in place on the back of the mistakes made to make sure they will not happen again and that if families continue to have concerns or questions to which they need answers, the hospital and the HSE will provide them. People should not have to go to court to have basic questions answered about patient care and patient safety in the hospital.

The problem is that it has not been patient-centred and that people are going to court because there is no other avenue available to them to get justice. I mentioned one of the 11 patients who was identified in the report as having received a misdiagnosis or in respect of whom there was a delayed diagnosis which had resulted in severe negative outcomes for his health. Between March and October 2016, the now 71 year old who is a husband, a father and a grandfather had three chest X-rays, in which his cancer was not picked up. The radiologist whose work was reviewed is not the only one who was involved in the case; there was another doctor who reported on at least one of the scans. The symptoms persisted and, at the insistence and because of the persistence of his wife, the GP referred the man in question for another X-ray in early 2017 when his lung cancer was finally diagnosed. The error had not been detected and despite the delayed diagnosis, he was scheduled for a CT scan in June that year, months after the misdiagnosis had been identified. His wife persisted and ensured that the scan was brought forward to April. It was discovered that the cancer had spread at such a rate that it was wrapped around the main artery to his heart. He went through what his wife described as "horrific treatment", but it was too late. I am informed that he only has a short time left and that the family firmly believe that if the cancer had been detected in any of the three earlier X-rays, it would not have been terminal. They have asked me to make the point that they have to fight for appointments in the health service to receive the care and treatment needed. They have to fight for grant aid in order to provide such basic things as a downstairs toilet in order that the man in question who was failed by the health service can live out his final days in comfort. He is on oxygen 24 hours a day and his family are devastated. They are appealing to me to ask the Tánaiste, the Taoiseach and the Government not to force an individual who has been so let down and failed to go through a complicated legal process. We need to ensure we wrap him and his family in the supports available, provide grant aid without them having to fight for it and appointments without them having to demand that his treatment be fast-tracked. It is not patient-centred and the family should not have to go to court. I want assurances from the Tánaiste that everything that can be done will be done to provide the best treatment available for the individuals affected in whatever days they have left and that a process will be put in place to avoid their having to take the legal route.

The family to which Deputy Pearse Doherty refers is clearly going through a very traumatic time. I assure him that the State, through the HSE, Kerry University Hospital and the Department of Health, will do everything it can to ensure the individual concerned gets the maximum care possible to manage what sounds like a case of terminal illness.

My understanding is that three legal proceedings have been issued in relation to cases that were dealt with in the report. The State Claims Agency will be managing those cases. It is always the objective of the State to try to deal with such cases in a patient-centred compassionate manner to prevent families having to go to court. That is not always possible but that is what the State Claims Agency will try to do.

This Sunday a 34 year old mother will leave her home in Wilton in Cork city and travel up to Dublin. On Monday she will head out to the airport and take the 7.50 a.m. Ryanair flight to Barcelona. Her name is Noreen O'Neill. She is the mother of a two year old boy, Michael, her first and only child. Michael will not be going on the trip as flying is not good for him. He was born with bilateral frontal polymicrogyria, a drug-resistant epilepsy. The condition caused Michael to suffer up to 20 convulsions per day before he even reached his first birthday.

The Irish health service offered Noreen ten different anti-convulsive medications for Michael but, unfortunately, none of them worked. In January of this year Noreen began treating Michael with cannabidiol, CBD oil, which served him well and for four full months he was seizure free. When the seizures returned in the summer Noreen increased Michael's CBD dosage. He is now at maximum dosage but the seizures, far fewer than before the treatment began, have not gone away. Noreen tried to get a licence for tetrahydrocannabinol, THC, under the licensing system introduced by the Minister for Health, Deputy Harris. However, each one of the three neurologists she approached declined to apply for the licence, which left Noreen with two choices: watch her son stay gripped by seizures, as they possibly worsen, or go to Barcelona. Barcelona is the home of the Kalapa Clinic, which has been overseeing Michael's CBD dosage in recent months via Skype. It is at the Kalapa Clinic that Michael's first prescription dosage of THC is now being made up. Noreen O'Neill will fly back into Dublin Airport at midday next Wednesday with enough THC to last Michael until the end of January.

Does the Tánaiste feel any sense of shame that he is a Minister in a Government which forces Irish women to go abroad for healthcare for their children? Does he accept the very fact Noreen has to make this journey is a sign that the licensing arrangement is at best inadequate and falling short for many people? Will the customs officials take Noreen to one side next Wednesday and confiscate her child's medicine? Does the Tánaiste agree that the law should not be an ass and must change so as to provide for the healthcare needs of the population and to prevent this kind of situation from happening in future?

I am not familiar with the individual case to which the Deputy refers but I am familiar with the issue and I have been personally involved with other families affected by it. The cannabis for medicinal use access programme the Government is to implement aims to facilitate access to cannabis-based products or preparations that are of a standardised quality, and which meet an acceptable level of quality assurance under the manufacturing process. The programme will provide access for patients who are under the care of a medical consultant for the following medical conditions which have failed to respond to standard treatments: spasticity associated with multiple sclerosis, intractable nausea and vomiting associated with chemotherapy and severe treatment-resistant epilepsy, which appears to be the issue to which Deputy Barry refers in relation to Michael.

An expert reference group has drawn up operational, clinical and practice guidelines for healthcare professionals treating patients through the programme and has advised that cannabis oils should be used for the purpose of achieving accuracy and consistency of dosage for patients. Departmental officials are working on secondary legislation in the form of three statutory instruments which will underpin the access programme. The Government and I do not think it is appropriate that politicians are the ones making decisions as to what is appropriate health treatment for children or adults.

We did last night.

That was not in relation to drug treatment. What we are trying to do here is ensure that medical practitioners - consultant doctors - can work with families, like the family mentioned by Deputy Barry, to ensure that children are getting appropriate treatment and that we can import where appropriate treatments that are not available in Ireland. The Minister has shown more than willingness to facilitate the licensing for that on application. I am not aware of a single application that has come from a consultant to import medicinal cannabis that has been refused. There is a process here. A number of Deputies have repeatedly raised the issue to try to ensure that we have a streamlined system that works with families. That means mothers do not have to travel abroad, to Amsterdam, Barcelona or elsewhere to bring back products, and that we can have a system where in certain circumstances children can access drugs that need to be imported from abroad. However, that does need to be in the context of the supervision and recommendation of a consultant doctor, who is trained to make medical decisions in the interests of patients.

There is a system in place but the system is not working. There are thousands of people in this county who need medicinal cannabis, sometimes for their children. How many have got the licence? Only 12 have got the licence, which means that less than 1% of people who need it have got it, and 99% of people who need it have not got it. One of the reasons for that is there is a chill factor for neurologists. THC is still illegal below a very low dosage and neurologists are nervous about that. THC is a schedule 1 drug that is not prescribed for medical purposes. That needs to change to the way it is in the Netherlands.

The Tánaiste said that people should not have to go abroad under the system but people still have to go abroad even if they have the licence. Vera Twomey has to go to the Netherlands in order to get the treatment for her daughter Ava, as do other people who have licences. Even if one is lucky enough to be in the 1% the Government still forces people to go abroad for the healthcare needs of their children.

This is going to be a big issue in the next week. Noreen will post reports on her Facebook page, including videos of her travel experience and her journey. People will watch that and they will look very carefully to see what the customs officials do next Wednesday, whether they take her aside and confiscate medicine that her child needs or recognise reality and allow her back into the country with the medicine that is needed for her son.

I put it to the Deputy that these issues need to be resolved in a way that prioritises the healthcare of the children. By and large, it is children we are talking about. Only 12 applications for import licences have been made and they have all been granted. The Minister has shown a willingness to try to ensure that when a doctor seeks an importation licence for a patient in his or her care, that licence is given quickly. We are also trying to ensure neurologists understand that these products are available, although they are somewhat limited in terms of where we can source them from. My understanding is that only Netherlands and Canada are licensed to export these products.

Department of Health officials are working intensively to try to ensure that we can streamline the process for appropriate drugs or cannabis products to come into Ireland so that children can get the treatment they need when then need it. That is perhaps a different thing from what Deputy Barry is asking for. The only focus of the Government and the Minister is to ensure that appropriate products of the right standard are being used by patients in Ireland under the supervision of doctors. We are working with the families concerned to ensure the process operates in a timely and streamlined manner.

I listened with interest to a report on RTÉ's "Morning Ireland" last Wednesday. The report outlined how health administrators and hospitals are asking people to use minor injury units where possible to avoid having to go to busy emergency departments. People attending one such unit in Smithfield in Dublin were glowing in their praise for the speed with which they were being seen and treated for minor injuries and ailments. They compared the experience with their previous experiences of spending hours waiting to be seen at hospital emergency departments.

That unit is one of 11 minor injury units dotted throughout the country that were designed to take the pressure off emergency departments. They deal with broken bones, dislocations, sprains, minor scalds and burns. I know from speaking to staff on a visit to the unit in Roscommon that it takes an average of 55 minutes from the time a person comes in the door until he or she goes back out having been seen and treated. I also know from a visit to the emergency department at University Hospital Galway that patients sitting in the waiting room for hours on end face a screen that pops up with a message advising them to use their local minor injury unit as a speedy alternative to the emergency department. It is good advice, but for the fact that Galway is the only major urban area in the country that actually does not have such a unit.

I have raised this matter before in the House. The first time was during Leaders' Questions two years ago with the then Taoiseach, Deputy Enda Kenny. As recently as March of this year I raised it with the current Taoiseach. At the time, the Taoiseach, Deputy Varadkar, agreed that there was merit in my suggestion for such a unit to be opened at Merlin Park University Hospital in Galway. He added:

It works in Dublin, Limerick and Cork. Why would it not work in Galway, therefore? I will certainly appraise the proposal and discuss it with the Minister for Health and the HSE.

Unfortunately, I am still waiting to see the proposal being acted upon. The idea is what we could call a no-brainer. More than 60,000 people every year are crowding into the cramped and outdated emergency department at University Hospital Galway. Three quarters of them are discharged after being seen and treated without being admitted to hospital. Most of the 45,000-plus people would benefit from the availability of the option to go to a minor injuries unit where they could be seen and treated in a fraction of the time it takes today. As the Taoiseach put it, there are injury units in Dublin Limerick and Cork - there are two more in Cork county - why not Galway?

University Hospital Galway is one of the busiest hospitals in the country with ever-increasing waiting lists and growing numbers spending nights on trolleys in the corridors of the emergency department. All of these people would benefit from a minor injuries unit. If funding were allocated, it could be up and running next year. When will the Government stop paying lip service to the idea and actually follow up with action to provide a minor injuries unit for Galway, based at Merlin Park University Hospital?

I thank Deputy Grealish for raising this issue. Approval was given in May 2017 to the Saolta University Health Care Group, which oversees the hospital system in the west and north west of the country, to conduct an options appraisal for future acute hospital needs in Galway. As the Deputy in aware, the Galway University Hospitals operate over two sites, including the model 4 hospital and the Merlin Park site. It is important that services planning is done in an integrated manner between both sites.

As part of the options appraisal the Saolta group will undertake a medium-term planning project to assess the population health needs for the hospital catchment area to inform existing and future service needs. The assessment will provide an options appraisal for the infrastructural requirements needed in Galway to facilitate the delivery of safe high-quality timely acute elective and cancer care for patients throughout the west and north west. This assessment will outline a comprehensive plan to address requirements for unscheduled and scheduled cancer and maternity-paediatric care, including key enabling diagnostic and support functions. The new emergency department block envisaged under Project Ireland 2040 will also be considered in the context of the options appraisal.

Saolta University Health Care Group has advised that the options appraisal will be completed in the first quarter of 2019. I am advised by the HSE that there are no specific plans at present to develop a minor injuries unit at Merlin Park. However, there is continued focus on ensuring that Merlin Park capacity is used to ease pressure on emergency acute and complex elective care at University Hospital Galway, which is the issue Deputy Grealish is raising. The Galway University Hospitals continue to review patient services suitable for transfer to Merlin Park. Similarly, administrative logistical and support functions that are not location-sensitive may be redeveloped at Merlin Park University Hospital.

I am also advised that Saolta University Health Care Group is working with the HSE to examine the potential for development of a day services hospital block at Merlin Park subject to the usual capital approval processes. A full appraisal is under way. It is to be finalised in the first quarter of next year. The issue Deputy Grealish has raised today will be very much factored into those considerations.

I asked the Tánaiste to provide a minor injuries unit on the grounds of Merlin Park University Hospital. There are 11 such units throughout the country in major urban cities. University Hospital Galway services the west. At one point the Tánaiste said there were no plans to build a unit, but then he said it would be considered in the report or appraisal that will be carried out.

It is time to get off the pot and provide one of these units for Galway. The emergency department in UHG is one of the worst in the country. Week after week it has the greatest number of people on trolleys, and the Government is doing nothing about it. The Government says it will build a new emergency department. That has been going on since I got elected to the Dáil in 2002 and still it is not being built. The Government is talking about the proposal to build a new hospital in Merlin Park. I will be dead and buried before that happens. Let us be honest and fair about that.

All I am asking is for a minor injuries unit. These units work successfully. I visited the unit in Roscommon and I was impressed with it. I call on the Tánaiste to give a firm commitment now that a minor injuries unit will be built on the ground of Merlin Park University Hospital without delay. The buildings are in place. It is only a matter of kitting out one of the units and putting in place two consultants and several nurses. We could take 60% of the people attending the accident and emergency unit in University Hospital Galway. I call on the Tánaiste to give a commitment that the Government will provide a unit for Galway. Why should Galway be different from any other major city in the country?

I hear what Deputy Grealish is saying. A full appraisal is going on right now - it has almost concluded - to ensure that the necessary health infrastructure in both sites of the Galway University Hospitals is factored in as part of capital investment in the future.

There is a commitment by the Government to build a new emergency department in Galway. That will be followed through. However, for me to make commitments on the floor of the Dáil when there is an appraisal that is almost completed-----

The Tánaiste said it will not be built.

I am saying that I am advised that there are no specific plans at present because the appraisal process has not concluded yet. We have not made a commitment in advance of that appraisal being finalised. That is the context in which the Department of Health will make further commitments for Galway. I hear the points the Deputy has made and they are not unreasonable. There are successful minor injuries units in other parts of the country that take pressure off accident and emergency departments. The appraisal process will conclude in the next couple of months and we need to factor in that thinking when considering future investment in Galway.

I point out to Members that Standing Order 29 sets out the timeframe for taking questions. It is a Standing Order the Members have written and adopted. I have written repeatedly to leaders to ask them to adhere to the time limits. The Committee on Procedures last week instructed me to write again. One of the considerations is that Leaders' Questions is broadcast, which necessitates adherence to time. It has been my observation that many Deputies studiously ignore the Chair when they are called upon to adhere to the time limit-----

The Ceann Comhairle should cut them off.

-----and in so doing are instigating gross disorder in the House.

The Ceann Comhairle will have to get cross.

This is quite intolerable. The committees of the House will have to consider the matter and decide what to do about it in the future.