HIQA Investigation into Midland Regional Hospital, Portlaoise: Health Information and Quality Authority

I welcome the witnesses to the meeting. I remind members, witnesses and those in the public gallery to switch off their mobile phones as they interfere with the broadcasting of these proceedings. Today, the committee has requested the attendance of officials from the Health Information and Quality Authority, HIQA, to discuss its investigation into the safety, quality and standards of service provided by the HSE to patients in the Midland Regional Hospital, Portlaoise. The HIQA report published last week examines patient safety and maternity services at Portlaoise. One of the roles of this committee is to ensure accountability on the part of the Department of Health and associated bodies, including the HSE, and on that basis, the committee requested an early meeting with HIQA to discuss its findings and recommendations. Committee members have discussed the report in private session and pending today's deliberations, it is fair to say that this is only the first step in the process of our committee dealing with this report. I thank Mr. Quinn, Ms Dunnion and Mr. Whelan from HIQA for coming today. I also wish to thank the families affected by this report for their tenacity, courage and bravery. They are meeting the Minister for Health, Deputy Varadkar, this afternoon to discuss the report.

The report raises a number of fundamental issues around governance, accountability, hospital standards and resources. As I already implied, our discussion today will be followed by a further meeting with the HSE. The committee decided in private session that, irrespective of what happens today, members need to hear from the HSE on this issue. We will also set about hearing from the families affected by this report. We hope that the recommendations of the report are implemented in full. Again, I thank HIQA for facilitating our early request for a meeting. Our key focus must be on the parents, families and children who had a negative experience with our health services and who raised issues of patient safety in maternity units. Our collective aim should be to ensure that we improve our maternity services so that they are safe services in which we can all have confidence.

I welcome Mr. Phelim Quinn, chief executive of HIQA, Ms Mary Dunnion, acting director of regulations at HIQA, and Mr. Marty Whelan, head of communications and stakeholder engagement with HIQA. Before we begin, we have received apologies from Deputies Ciara Conway and Catherine Byrne and Senator Imelda Henry. I wish to advise the witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to this committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise nor make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable.

I invite Mr. Quinn to make his opening remarks.

Mr. Phelim Quinn

I thank the Chairman. On behalf of the Health Information and Quality Authority, HIQA, I thank the Joint Committee on Health and Children for giving me the opportunity to discuss our investigation into the safety, quality and standards of services provided by the Health Service Executive, HSE, to patients in the Midland Regional Hospital, Portlaoise. As the Chairman noted, I am joined by Ms Mary Dunnion, director of regulation and by Mr. Marty Whelan, our head of communications and stakeholder engagement. We welcome this opportunity to appear again before the joint committee and to engage with members.

Following a request in 2014 from the former Minister for Health, Deputy James Reilly, in accordance with section 9(2) of the Health Act 2007, HIQA has investigated the safety, quality and standards of services provided by the HSE to patients in Midland Regional Hospital, Portlaoise. This is the seventh statutory investigation carried about by HIQA since 2007.

On 30 January 2014, an RTE investigations unit "Prime Time" programme was broadcast about the tragic deaths of newborn babies in Portlaoise hospital and the subsequent management of patients and their families by the hospital and the HSE. Following the broadcast, the then Minister of Health asked the chief medical officer of the Department of Health to conduct a preliminary assessment of perinatal deaths and related matters from 2006 up to that point in 2014 in the maternity services at Portlaoise hospital. Following publication of the chief medical officer’s report, the board of HIQA considered and agreed to a request from the then Minister for Health to conduct an independent investigation into the services provided by the HSE at Portlaoise hospital.

This statutory HIQA investigation has been carried out in line with the authority’s published terms of reference and published guidance in order to make recommendations to improve the safety, quality and standards of services provided by the HSE. Central to this investigation was the experience of a number of patients and families whose experience of care fell well below the standard expected in a modern acute hospital. The assessment of these patients and families’ experience reflects their experience of care and its aftermath when they raised concerns at local, regional and national levels of the HSE. I would like to acknowledge the courage and fortitude of the many patients and families who made contact with the authority to outline their experience of care within Portlaoise hospital. It should be acknowledged that their efforts, harnessed with the required actions of those charged with delivering services, should ensure a better experience for those availing of services at Portlaoise hospital in the future.

This investigation examined the quality and safety of maternity and general clinical services at the hospital, and the Health Service Executive governance arrangements in place nationally, regionally and locally.

In his report, the chief medical officer said two HSE reviews into breast cancer misdiagnosis cases at Portlaoise hospital, published in 2008, should have provided a very strong case for external oversight and support to Portlaoise hospital as it dealt with those issues. HIQA strongly reiterates this view. Throughout this investigation it has found examples of weak oversight and variable levels of action by the HSE at national, regional and local level in relation to risks to patients at Portlaoise hospital. Two previous HIQA reports relevant to Portlaoise hospital were the investigation reports into Ennis and Mallow hospitals, published in 2009 and 2011. Both reports stress that patients with complex needs should be directed to hospitals with the necessary staffing, competence, infrastructure and equipment for safe and effective care. Our latest investigation found that the HSE – as the provider of health care services – failed to take decisive action on defining the role of Portlaoise hospital, its model of care and the nature and profile of services that could be safely delivered on the site in the context of the findings of previous investigations.

As the committee is aware, this investigation was initiated as a result of very negative experiences of a small but significant number of patients and their families at Portlaoise hospital. When the investigation started, HIQA was contacted by or received information on 83 patients and their families, most of whom had used the maternity services at Portlaoise hospital. While the purpose of the investigation was not to undertake a detailed examination of individual patients’ care, in line with the investigation work of other regulatory bodies internationally, hearing the experiences of service users is an invaluable part of this process. The experiences of these individuals and families helped to inform the investigation and gave a range of personal perspectives on the quality of care received and helped in shaping the findings and recommendations in the report.

Parents who spoke with the investigation team gave examples of poor communication with hospital staff where they were not afforded adequate explanations following an adverse event including the death of a baby or regarding a clinical condition. Some parents said they felt they were not entitled to an explanation. Others said that medical jargon left them feeling intimidated and unclear about what was being said. Parents found that such a lack of openness in providing information and explanations compounded their feelings of fear and grief. Parents also described significant delays in the time it took the HSE at all levels to respond to their requests for information and explanations following the adverse events. HIQA is aware that delays in investigation of adverse events have occurred elsewhere in the health services. The current HSE review process is often protracted and leaves families with unanswered questions pending completion of a final report, thereby increasing their upset and trauma. As a result of these delays safety issues may potentially remain unidentified and unresolved for lengthy periods of time.

There were many reasons the HSE should have maintained very close oversight of the quality and safety of services at Portlaoise hospital. These reasons included local and national HSE inquiries and clinical reviews into patient-safety incidents, significant service failures, statutory investigations of hospital services, and resultant publication of findings and recommendations. However, there was no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks identified there.

Another concern of the investigation team was that for seven years prior to the chief medical officer’s report, the State Claims Agency through its clinical indemnity scheme knew of actual or potential risks in the maternity services at Portlaoise hospital. HIQA recognises that the State Claims Agency does not have statutory powers by which it can compel healthcare institutions, including the HSE, to engage with it or to implement any recommendations which it may make. However, we are concerned that the interaction between the State Claims Agency and the HSE on the sharing and use of available information did not result in effective mitigation of the identified risks.

The investigation team found that Portlaoise hospital continues to provide undifferentiated, namely, in all manner of conditions, emergency services 24 hours a day seven days per week. It also provides undifferentiated surgical services where there is a low number of complex surgical cases going through the hospital. The investigation team found that Portlaoise hospital had major deficiencies in corporate and clinical governance arrangements. Although described as a model-3 hospital by senior HSE and local hospital staff, the investigation team found that the hospital was not governed, resourced or equipped to safely deliver this level of clinical services. In 2012 and 2013 HSE itself specifically identified clinical risks associated with surgery, emergency medicine and acute medicine and said that surgical services at the hospital should cease.

Following interaction with HIQA about concerns for the governance at Portlaoise hospital, in 2013 the then HSE regional management altered the local management arrangements. The purpose of the alterations was to increase the interaction between regional and local management structures and bring decision-making powers onto the hospital site. However, despite overwhelming evidence to suggest that the local management team at Portlaoise hospital was struggling to deliver the service, there is no evidence to show that the regional HSE managers took effective control of the situation at that time. The senior hospital management committee was responsible for providing safe, effective services through leading and directing performance of the hospital. The minutes of these meetings show little evidence that the committee was effective in identifying or implementing actions to address quality and safety issues within the hospital.

HIQA also concluded there were significant ongoing problems with workforce planning in Portlaoise hospital. The absence of a clear vision for the hospital, coupled with the national imperative to reduce the staff headcount, ensured that planning was focused on counting staff rather than on the type of services the hospital should be delivering and the competencies needed to deliver them.

Risk management structures in the hospital were poorly developed. Incident management at Portlaoise hospital was largely reactive and focused on recording incidents. It was evident that the deficiencies in risk management processes in the hospital contributed to the poor experiences described by patients who met the investigation team. As part of the investigation, HIQA assessed the prevailing patient safety culture in Portlaoise hospital using the safety culture index. The results, used to inform our lines of inquiry of this investigation, suggested that Portlaoise hospital did not have a strong patient safety culture.

Increasing pressure on maternity services at Portlaoise hospital was highlighted as far back as 2004. Deficiencies in midwifery staffing had been identified in a review carried out by the hospital in 2006. These issues were not substantially addressed until 2014, following publication of the chief medical officer’s report. At the time of writing this report, an interim management team including a general manager, risk manager and director of midwifery had been put in place and were effecting positive change. However, a senior obstetric lead had not been appointed to the maternity department to provide independent senior experienced, obstetric, clinical leadership - despite a direct request by HIQA to the director general of the HSE in September 2014 to do so following our concerns about the absence of adequate clinical leadership in the maternity unit and failure to progress a clinical network with the Coombe Women & Infants University Hospital in Dublin.

Since the chief medical officer’s report, midwifery staffing levels have significantly improved with the appointment of senior clinical midwifery managers, shift leaders, a bereavement specialist, a clinical skills co-ordinator and a clinical midwife specialist. One additional consultant obstetrician has also been appointed.

Clinical experts on HIQA's investigation team identified a lack of senior clinical leadership and supporting formal clinical network arrangements – and current staffing arrangements for non-consultant hospital doctors – as a serious concern and risk for the sustainability of the maternity services at Portlaoise hospital.

These experts considered it vital that a system of rotation be designed between Portlaoise hospital and a large maternity hospital such as the Coombe Women & Infants University Hospital. Setting up a clinical network incorporating Portlaoise hospital and the Coombe Women & Infants University Hospital is an essential first step in developing such a system of rotation.

Poor standards of multidisciplinary communication were highlighted by a number of people who met the authority. These concerns were reported as far back as 2007 and had not been addressed. Additionally, concerns over the governance arrangements for ultrasound scanning services and effective clinical audit at Portlaoise hospital were identified during our investigation. Specific issues relating to service capacity, staff competency and clinical oversight of the ultrasound service were acknowledged by the hospital management team.

Portlaoise hospital provides a 24-7 emergency service for adult and paediatric patients with any degree of seriousness or complexity of illness or injury who present at the hospital. The clinical governance arrangements in the hospital’s emergency department were unsatisfactory and over-complicated. Despite the fact that both the HSE’s emergency medicine programme and acute medicines programme had previously identified concerns over these arrangements, the inherent risks remained unaddressed.

The HSE’s own emergency medicine programme considered that the emergency department was not appropriately resourced to provide a 24-7 model of emergency care. Also, the HSE’s unpublished performance review in 2014 concluded that a 24-7 emergency care service at Portlaoise hospital was not clinically sustainable. At the time of this investigation, the clinical profile of emergency department patients is still not being actively assessed to inform the type of service that is required to best meet the needs of those patients presenting to it.

The overall volume of critical care activity within the intensive care unit of the hospital was low. The intensive care unit does not meet the minimum requirements for critical care, patient confidentiality and privacy, and it was not fit for purpose. Senior clinical staff were aware of the limitations of the care that could be safely provided there. They confirmed that if necessary, patients are transferred to a more appropriately resourced hospital.

A report by the HSE in 2014 recommended that critical care services in the hospital should be discontinued. In light of this HSE review and the concerns of senior local clinicians, the investigation team is not assured that critical care services are sustainable in Portlaoise hospital. The surgical services at Portlaoise hospital operate a 24-7 emergency service basis, catering for all degrees of surgical illness or injury arriving at the hospital. Most hospital inpatients using the surgical services at Portlaoise hospital were admitted through the emergency department.

Two recent HSE reviews of the surgical services at Portlaoise hospital both concluded that the hospital on its own was not structured to provide safe, acute and preplanned surgical care. The investigation team found that low numbers of complex surgical procedures were being carried out at the hospital. As previously reported by the authority, surgeons who do not have the opportunity to treat sufficient numbers of patients or carry out a sufficient volume of procedures run the risk of becoming de-skilled. This potential risk has not been addressed at Portlaoise hospital.

The investigation team found that medical services at Portlaoise hospital required significant restructuring and resourcing in order to deliver a service aligned to the HSE’s acute medicine programme. Despite the recommendations of the HSE’s acute medicine programme, the hospital did not have a medical assessment unit or a bed management structure. This investigation also found that the medical team was under-resourced, with local clinicians reporting that two extra medical consultants were needed for care of the elderly and endocrinology. These appointments would also help release the hospital’s clinical director from general medical duties for 25 hours each week in order to increase time for the functions of the clinical director role.

The diagnostic imaging service at Portlaoise hospital is significantly under-resourced with a lack of resources preventing the development of strong clinical governance arrangements to ensure the quality and safety of service delivery. At the time of reporting, the diagnostic imaging service is overly reliant on one clinician. Therefore, this model of care is clearly not sustainable.

The findings of this investigation reflect an ongoing failure on the part of the HSE to evaluate the services provided at Portlaoise hospital against the volume of patients attending the hospital and the profile of their clinical needs, and the findings of aligned risks and recommendations identified in previous local and national reviews and investigations conducted by this authority and the HSE. The findings of this HIQA investigation highlight again issues and recommendations that have been identified on a number of occasions previously in both internal HSE reviews and independent HIQA investigations.

This investigation concludes that Portlaoise hospital was allowed to struggle on despite a number of substantial governance and management issues over the quality and safety of services. Sufficient action was not taken by the HSE at a national, regional or local level to address these issues.

The experiences outlined by patients and families during the course of this investigation were disturbing when viewed within the context of the delivery of a modern health service. These experiences highlight significant deficiencies in the delivery of person-centred care at Portlaoise hospital. Poor experiences by patients and families were compounded by ineffective governance arrangements at all levels of the HSE with the result that the patient’s voice was ignored, and valuable insights and learning were lost.

The HSE must now address the risks and deficiencies identified within this report in order to improve the quality, safety and experience of patient care in Portlaoise hospital. It must also ensure that where similar risks and deficiencies exist in other hospitals, these are addressed as a matter of urgency. The HSE governance arrangements to support the implementation of the national recommendations contained in this investigation must be clear, with a named accountable person or persons with overall delegated responsibility for implementation. The implementation plans should include clear timelines and identified individuals with responsibility for each recommendation and each associated action.

A national maternity strategy must be developed and published as a matter of urgency. We welcome the establishment of a steering group to advise on the development of such a national maternity strategy. The authority acknowledges the work that has been done to date to incorporate the maternity services at Portlaoise hospital into a clinical network with the Coombe Women & Infants University Hospital and welcomes the recent signing of a memorandum of understanding between the Coombe Women & Infants University Hospital and the Dublin-Midlands hospitals group of the Health Service Executive.

In light of the findings of this investigation, the authority has made eight recommendations which must be implemented to ensure that risks and deficiencies identified are addressed at both local and national level to ensure the delivery of safe and consistent patient care. Among the recommendations in our report is the creation of an independent patient advocacy service to ensure that patients’ reported experiences are recorded, listened to and learned from, and reports published. Lessons learned should be shared between hospitals within the new hospital groups, between hospital groups and nationally throughout the wider health system. I hope to address some of our recommendations in more detail in reply to questions from committee members. It is imperative that these recommendations are fully implemented and that a clear timeline is set out and followed up, with named individuals taking responsibility for the implementation of each recommendation.

Given the significant system-wide recommendations in the report, it will be vital that there is the necessary political commitment to their managed implementation in order to drive further improvements in the quality, safety and governance in our health services. The authority therefore recommends that the Minister for Health should establish, as a priority, an oversight committee in the Department of Health to ensure the implementation of the recommendations in this HIQA investigation report.

I thank the members of the Oireachtas Joint Committee on Health and Children for inviting us here today. I look forward to their questions.

I thank Mr. Quinn. Deputy Ó Caoláin has had to go to the Dáil Chamber to take part in the Topical Issue debate. I will call him when he arrives back. I will begin by calling Deputy Kelleher, who has five minutes.

I welcome the witnesses and thank them for the publication of the report. When speaking about this report, we must be mindful that it came about because of the very tragic circumstances that arose for at least five families involving the maternity services in Portlaoise and elsewhere.

In 2008 there was an investigation carried out into the misdiagnosis of breast cancer in Portlaoise. Is it within HIQA's remit to monitor, visit, or assess a hospital? Were alarm bells ever raised in the period prior to the Minister's request for HIQA to carry out an investigation under the 2007 Act? The 2008 investigation showed difficulties in governance and patient safety. Will Mr. Quinn clarify whether or not HIQA engaged with the hospital in these areas?

The report is damning. We cannot assess it any other way. It calls into question accountability and commitments in terms of basic governance and patient safety, not only in the context of maternity services but right across the spectrum of services provided at the hospital. Mr. Quinn has said that there must be a designated, named person in the hospital who is responsible for patient safety. Did Mr. Quinn find in his investigation that there was a complete absence of accountability in terms of people's roles and responsibilities?

From reading the report and the executive summary, it seems that there was very little emphasis put on patient safety at local, regional and national level, right throughout the HSE. Red flags were being raised on a continual basis and some people would say that there were alarm bells ringing everywhere, yet there seemed to be inactivity or an inability to understand the seriousness of the situation. Was the weakness at local or national level or was there just weakness across the whole system right to the top in terms of understanding the deficiencies in the hospital itself? Will Mr. Quinn provide clarity on that?

The chief medical officer's report was also damning. It spurred some activity in terms of addressing some of the deficiencies but, again, this seemed to be quite lethargic, in spite of the recommendations made in the report and the findings made before HIQA began its investigation under the 2007 Act. It seems that there is quite a distance to go, even on the recommendations that were outlined in that report, which was published over a year ago. There is still no lead clinical obstetrician or proper safety governance in place. At present, HIQA cannot say with 100% certainty that all services are being operated in a safe manner in Portlaoise. That is clearly something that gives rise to concern. I do not want to fuel fear or concern but I believe that the public have an entitlement to believe that when they engage with the HSE, as its stated mission is to provide safe care, that they receive this, at the very least. That does not seem to have been part of the culture at Portlaoise. Serious deficiencies were exposed in 2008 in the breast cancer misdiagnosis but there were concerns from as early as 2004 about the lack of resources in the maternity and midwifery services, and about the lack of consultant leads, not only in maternity but throughout the hospital.

Mr. Quinn has referred to the State Claims Agency, and the report indicates that it corresponded with the HSE. Did it express concerns about the number of claims coming from the hospital? Were those claims in relation to maternity services or were there other claims coming from Portlaoise hospital? In that correspondence, does the State Claims Agency outline that something should be done to address the number of claims? Was the hospital informed that it was out of kilter with other hospitals of similar size?

I have asked a lot of questions but there is a lot in this report.

Will the Deputy please conclude?

Have I been speaking for five minutes already?

Neither governance nor clinical and general resources were in place in Portlaoise even though it was regarded as a level 3 hospital. Mr. Quinn referred to this in his statement today and it is highlighted in the executive summary. What is the motivation to pretend that a service exists when, in effect, that service cannot be delivered? Was the HSE in some way trying to obligate itself to provide a service that it clearly could not provide or was not willing to resource? I find it extraordinary that the hospital is identified as a level 3 hospital. In the emergency department, for example, the number of emergency consultants was exceptionally limited, and the broader hospital just simply was not resourced to deliver a level 3 service. Was there any analysis carried out as to why the HSE said it was providing a service that it simply could not provide, or was unwilling to, or could not, resource?

We have had the Tania McCabe case in Our Lady of Lourdes and the Savita Halappanavar case in Galway and there have been investigations in Ennis and Mallow. There seems to be an inability on the part of the HSE to cross-fertilise best practice throughout its organisation. Has HIQA looked at that? Why is that the case? If something is deficient in a hospital, one would assume that, at national level, other hospitals would be assessed to see whether those deficiencies exist and what practices can be put in place. Why does that not happen?

Given the significant system-wide recommendations in the report, it is vital that there is necessary political commitment to manage their implementation in order to drive further improvements in quality, safety and governance of care provided in our health system. That is an indication that sometimes when hospital services are being withdrawn or downgraded there is political involvement and very often the consequences for patients and the need to ensure that there is quality and safety provided in hospitals are secondary considerations. Will Mr. Quinn elaborate on what he means by political commitment?

I thank Mr. Quinn for his hard work on the report and for his presentation today. I mean no intrinsic disrespect when I say that the core recommendations seem to boil down to one group of administrative oversight, investigative staff in HIQA, commenting on the generally inadequate administrative responses of another group of administrative staff, that is, the HSE and the staff on the ground in Portlaoise hospital. On the role of clinicians, the lack of a clinical lead is highlighted - again, the lack of a clinician who is identified as having an essentially administrative role in the running of the department. Mr. Quinn will be aware of the data presented some time ago by Dr. Michael Turner, who is the HSE lead in obstetrical care, which showed that Ireland is at the very bottom of a league table of obstetricians per head of population. The question has to be asked, how many of the problems that arose in Portlaoise or other hospitals would have arisen if an adequate cohort of fully trained specialists were available to provide the care?

Does the HIQA report provide a figure for how many obstetricians occupy posts in Ireland? How many posts are empty? How many of the occupied posts are occupied by locums? What is the average duration of a locum's appointment in the system?

It is bad enough if there are far too few senior specialists in an institution - all kinds of pathologies happen as a result of that. One of them is that far too much work is devolved to trainee doctors. The report refers repeatedly to situations with non-consultant hospital doctors. With respect, unless HIQA is taking on a role in medical education, the presence or absence of one or a million junior doctors in any hospital should be a subject of monumental irrelevance, because they are trainees. They are there to train. They are not there as service providers. The fact that we depend on them so heavily, not just in this hospital but in much larger hospitals, for the provision of routine health care service, is an indictment of the way that we have structured our hospital system. I know the answer to some of these questions. We have a very small number of obstetricians and we have an unusually large number of locums. I worked in two fine medical institutions in the United States and one in London before I came back to Ireland. There were never locums because the units were sufficiently large, muscular and well-staffed that they could absorb somebody going sick, having a family crisis, or having paternity or maternity leave without the necessity of bringing in locums. That is the way a good well-run system should be.

There should be enough people in place to provide cover for each other and continuity of care. That is no disrespect to the individual locums, many of whom are fine people who are good solid medical graduates and well trained. However, the very act of being temporary in a job means there will be an issue with the continuity of care that is delivered.

A number of other questions arise. Has the authority made any recommendation that there is or is not a special care baby unit in Portlaoise hospital? How many neonatologists are there in Ireland, how many are in Portlaoise hospital and how many are in that hospital group? Another question must be asked of all of us in this room, and obviously this is a fight in which I have had a dog recently. Would anybody want their child to be born in a hospital where a neonatal intensive care unit or a neonatologist specialist paediatrician was not available should they be necessary or unless one had the certainty that there was a well trained, experienced obstetrician available should something unforeseen and catastrophic occur in the course of a pregnancy?

I probably sound a little subdued because, at this stage, my morale is shot on this issue. I returned to this country 22 years ago and 21 years ago, after a respectable period of silence, I started pointing out the incredible deficiencies I saw not only in the cancer service but also in the health service in general. I see little effort or little attention being paid to fixing the fundamental problems we have. With no disrespect to the witnesses, there is a heavy emphasis in these recommendations on administrative efficiencies, on the need to appoint more people to essentially bureaucratic and administrative positions and on the need to set up new agencies. These are very subsidiary priorities in a system which is so starved of specialists that catastrophes such as those we have seen will continue to occur while we are talking about it. Good Lord, was there ever a country that found itself so much in the glare of the international spotlight for deficiencies in its obstetric services as this country - I will not personalise it - after the very well-known tragedy that occurred several years ago? To think that we are still scratching our heads and trying to work out how to get the administration in place is very depressing.

In the absence of Deputy Ó Caoláin, I will call the following members in turn, Deputy Regina Doherty, Senator Colm Burke and Deputy Mitchell O'Connor. They have three minutes each.

I do not have time for a chat as I have so many questions. I thank the witnesses for attending the meeting. Regarding the report issued on Friday, how does it differ from the original draft report the authority had issued to the Minister and the HSE? Did it differ substantially arising from the threat of legal action?

Second, the first recommendation is probably the weightiest, notwithstanding all of the other deficiencies. The authority talks about immediately setting up, between now and next May, an independent patient advocacy service. How does the authority understand the word "independent"? How does it envisage it running? The authority has challenged the HSE to establish it. That is a contradiction in terms in my book. This relates back to the authority's investigation team. The response of the patient safety director and his team in the HSE in the last two years to doing their job with regard to patient advocacy has been to fund and finance the establishment of Patients for Patient Safety Ireland under the leadership of a lady called Margaret Murphy who, coincidentally, was on the authority's investigation team. How was the authority's investigation team selected? I assume the authority did not find any conflict of interest because Ms Murphy is on the team but did any conflict arise before she was part of the independent investigation team, since she is on the HSE's payroll?

When the authority went to Portlaoise was it made aware of the HSE's internal patient safety culture survey which it conducted in Portlaoise last year? If the authority was, what were the findings of it? What were the recommendations of the HSE's internal review and were any of them implemented? Has the authority any thoughts as to why the HSE in Portlaoise is not using the clinical indemnity STARS database to log adverse events and report incidents, as most other clinical practices do with regard to best practice in collating data? Does the authority think it odd that, aside from Portlaoise, the HSE's patient safety agency and directorate has not conducted even one independent survey of the patients' experience, views or anything else, other than establishing Patients for Patient Safety Ireland, in over two years? In fact, as far back as 2013 it actively starved the people who were responsible, on behalf of the State, for providing independent patient surveys on patient experience and data collection, because it could not control and manipulate the data, as there was no direct connection for it.

I have two further questions, Chairman. Two matters scream for attention but they are not highlighted in the authority's report, although they were highlighted in the CMO's report. The CMO's report highlighted the fact that the 24-7 emergency services being operated in Portlaoise only have a consultant on site four days per week for six hours. What happens in the accident and emergency department for the other three days and for all of the hours there is no consultant present? When the authority went to Portlaoise to carry out its investigation why did it not immediately recommend that the 24 hour service in Portlaoise should be closed or properly manned with immediate effect? Perhaps the personnel were put in place between the CMO's report being issued in February and the authority issuing its report.

As a result of the CMO's report an additional 16 midwives were added to the staff, which is extremely welcome given the low morale and the outcomes in Portlaoise in recent years. There are 19 places in this country where one can have a baby. What is the proportional ratio of midwives to births in each of the other 18 locations and do they come up to standard as to what should be in place? If not, what are we doing about it at national level?

Finally, a question was raised today in the Chamber. There was a really tragic incident in Cavan yesterday. There was a query regarding whether HIQA was asked-----

The issue of Cavan hospital is not relevant to our meeting today. We will discuss it again.

It is not, but the question relates to HIQA. Was HIQA asked in January last year by the then Minister to conduct monitoring of the maternity unit in Cavan hospital in line with national standards of maternity services, or is HIQA still waiting on that request?

Deputy Ó Caoláin has returned so I will call him next. Then I will call on Mr. Quinn to respond before calling on other members.

I apologise for not hearing the full presentation from Mr. Quinn, but we had prior sight of his presentation and I had the opportunity to read it. I am at a disadvantage as I do not know what questions my colleagues asked so if there is repetition, I apologise.

What changes, if any, did the authority make to the original draft report before the publication last Friday? Were any changes made or did the authority hold to the draft that was first advised to the HSE? Has the authority met with the families concerned since the issuance of the threat of legal action to prevent publication of the report and, if not, will it with regard to the Portlaoise cases? I understand the Minister is meeting them today. Has the authority done so, or will it, in the context of the publication of the report?

The first recommendation refers to an independent patient advocacy service. One of the deficiencies in the relationship between HIQA and the HSE is that there is a serious lack of compellability to act on findings and recommendations contained in reports. I am unclear about the status of HIQA's relationship with the HSE in respect of the publication of reports and the recommendations contained therein. A recommendation, by its nature, is not necessarily an insistence that one must do something. Will the witness expand on that?

I have read what the authority says in the first recommendation regarding an independent patient advocacy service where patients' reported experiences are recorded, listened to and learned from. That is far too weak; it is not strong enough. We need something much stronger. The recommendations contained in the report are not made lightly. They are a professional assessment of deficiencies and needs within our health system, be it acute hospital settings or other settings across the health care sector.

I believe we need a patient safety authority, of which HIQA would be a significant component. I understand this was part of the programme for Government agreed in 2011, but that it has been parked in the period since. A patient safety authority would not only give teeth but would give certainty to those of us dependent on the health services, public health services in particular, that the required steps will be implemented. This must happen and I am anxious to hear Mr. Quinn's views on that. The second recommendation is that the Department of Health should ensure implementation of the recommendations of HIQA. This echoes the point I made already.

On the fifth recommendation, I welcome the proposition of the appointment of a director of midwifery in all maternity units across the State that do not have such a director. I note the sixth recommendation recommends systems to support a competent and appropriately resourced workforce. These two recommendations aside, there is no other mention of staffing or of nursing midwife shortages in any of HIQA's recommendations. Despite no explicit reference to overworked and under-resourced staffing at the Portlaoise maternity unit, and by extension across all maternity units, does HIQA accept there is a critical shortage of properly qualified full-time staff across all obstetric maternity settings? Does it accept this is a serious element in regard to the tragic outcomes at Portlaoise, at Cavan and other hospital sites?

I do not intend to stray, but I have just come from a Topical Issue engagement with the Minister of State in the Department of Health on these matters. It has been reported that the former Minister for Health, Deputy James Reilly, stated in an interview he gave in Cavan that he would request HIQA to look into the situation. He suggested that priority be given to a review of the maternity services in Cavan General Hospital against the national standards, in tandem with the address of the Midland Regional Hospital maternity unit at Portlaoise. However, the Minister of State, Deputy Kathleen Lynch, has just advised me that this was a "request".

We will have an opportunity at another forum to deal with the issue of Cavan hospital.

I am referring to it in the context of the Portlaoise report because that was what was suggested. I am only asking for clarification on the distinction between two words.

In fairness to HIQA, the report on the other hospitals is ongoing and is not concluded. Is that correct?

Mr. Phelim Quinn

Yes.

Therefore, regrettably, we do not have any reports on Cavan 13 months on. I do not seek to go into the Cavan tragedies in detail, but am asking for an explanation in regard to what are referred to as "formal orders" issuing from the Minister and "requests" issuing from the Minister. It has been suggested there is a significant difference. In this instance, a "request" was made, but that is not a compulsory demand of HIQA by the Minister. Will Mr. Quinn clarify that, given that the Minister indicated at the time the review would be done "in tandem with" the Portlaoise review? It was reported to me a few moments ago that HIQA made contact with the HSE in this regard and details for the three incidents - now there is a fourth - have been furnished to the authority. When did this happen?

We have three other speakers to put questions, but we will take a response from Mr. Quinn before coming to them.

Mr. Phelim Quinn

There has been a significant range and diversity of questions, but I will do my best to address all of them.

Deputy Kelleher asked about HIQA's involvement, since 2008, after the breast cancer misdiagnosis issue at Portlaoise hospital. I will give a brief oversight of some of its involvement and will then pass on to my colleague Ms Dunnion. Following the 2008 activity, HIQA would have been in receipt of individual pieces of what we would call "unsolicited information" in respect of some risk issues within Portlaoise hospital. Also, through the conduct of a governance review under our monitoring against the national standards for the prevention and control of health care associated infections, we had escalated a range of issues into the HSE nationally in regard to risk management arrangements within Portlaoise hospital.

It was as a result of the accumulation of that range of risk issues, that in 2014, as was in our business plan, we agreed to conduct a governance review within Portlaoise hospital. That was simply because we had significant concerns accumulating about the hospital and felt there was a requirement for proactive engagement with it on that basis, under section 8 of the Act. However, the tragic events occurred in regard to the identification of a series of infant deaths on the "Prime Time" programme and then the ensuing investigation took over from our plans to conduct a governance review.

Was that governance review to involve the HSE or just the hospital?

Mr. Phelim Quinn

It would have looked at levels of governance, so would have looked at both. Our concerns were identified as concerns in risk management at local and regional level, so we would have needed to make an assessment of risk across all levels of the HSE and its impact on the safety of services at local level.

The Deputy asked about political commitment. We had made a series of recommendations previously, both to the HSE and the Department. In regard to our call for political commitment to the recommendations we make, this is linked to the questions put to us by Deputy Ó Caoláin. We reported previously to this committee and in previous investigations that at times we have found the recommendations made by HIQA have not been implemented. If we were to look at the range of recommendations across the seven investigations we have conducted, there are still significant deficits in the uptake and implementation of those recommendations. When it comes to the "compellability" of those recommendations, the current legislation on our monitoring and investigation function does not provide us with "compellability". However, if the plans in regard to health care licensing come to fruition, they would provide some form of enforcement framework that would be available to us.

I will now pass over to my colleague to respond to a number of Deputy Kelleher's questions on accountability and the CMO report.

Ms Mary Dunnion

Most of the CMO report was concerned with national recommendations, many of which would have been aligned with the maternity strategy and would have been identified by the authority as far back as 2013.

In the context of the recommendations in the CMO's report, some changes were made in the maternity hospital and benefits were noted. Let me give an example. One recommendation the CMO made was to have an interim management team for the maternity service. He identified significant deficits in the governance arrangements. What was disappointing for the investigation team was that, while that happened in the maternity service, the same governance arrangements remained unchanged in the general hospital because the interim management team was specific to maternity services. However, one could see the benefits of having an effective management team, a director of midwifery and a risk manager come on board in the maternity service. They are reflected in the report.

The recommendations were taken on board but the one that was of considerable concern to us concerned the networking into a clinical network, as in the case of the Coombe hospital. While we appreciated the difficulties that would arise in the context of a voluntary and statutory hospital and setting up those arrangements, we were significantly concerned about the lack of senior clinical leadership. This was reinforced by the clinical expertise of two obstetricians on the investigation team. We regard clinical leadership as an integral part of the important process of driving best practice, clinical supervision, clinical auditing and all the associated factors. We were so concerned because there was not senior clinical leadership with that level of experience in Portlaoise. The interfacing with the Coombe hospital had not happened. We wrote to the director general because we were concerned about this. Thankfully, at the latter end, four weeks before the publication of the report, the memorandum of understanding has been signed. Although it has not been implemented yet, we are aware that there is senior clinical leadership from the Coombe on-site in Portlaoise hospital. We very much welcome that development. However, we are obviously disappointed over how long it took.

Mr. Phelim Quinn

We have considered the State Claims Agency's concerns and how they were communicated both to the HSE and Portlaoise hospital itself. There was certainly evidence that there was an accumulation of concerns raised through the State Claims Agency’s own systems. It made numerous attempts to communicate those risks and the trending of those risks within Portlaoise hospital specifically. However, it seemed at times that this information did not translate into action on the part of the HSE. That would have been a very-----

Is that in regard to maternity services?

Mr. Phelim Quinn

Maternity services.

Why was that the case?

Mr. Phelim Quinn

That is a question for the HSE.

Has Mr. Quinn a view on that?

Mr. Phelim Quinn

We believe due regard was not had for information being provided by the State Claims Agency or the validity of that information. It is as a result of that ambiguity that we have made a recommendation on a more formal arrangement between the State Claims Agency, the HSE and the new hospital groups. We believe that arrangement needs to ensure the formal transmission of information, be it specific information or trend information, from the State Claims Agency.

Senator Quinn asked a range of questions about the specifics regarding obstetrics. The questions are related to the midwifery workforce. My colleague mentioned the recommendation we made in our 2013 investigation into the tragic death of Ms Savita Halappanavar. At that point, we very clearly recognised the need for a maternity services strategy for Ireland. That strategy would take into account the very question the Senator has asked us today: what is the current profile of the workforce within the maternity services, and what should it be in light of the remodelling of those services across the 19 or fewer units? We just do not know the number; the maternity services strategy itself would have been to determine that. There needs to be very clear clinical and midwifery input into the strategy to inform it from an international best evidence perspective.

We have been asked about the report itself and changes therein between our issuing of the draft version to the HSE in February 2015 and publication last Friday. I wish to be absolutely clear in stating there is very minimal change to the report. As a matter of fact, the substantive findings of the report have not changed at all. There are some minor changes that would be expected as a result of due process. An example, which we articulated on Friday, is that there was a significant challenge associated with our glossary of terms in the report so we expanded it quite significantly. The findings themselves, however, are not substantially changed. I reassure the committee fully on that.

Does Mr. Quinn agree that it is regrettable that there was a public exchange between HIQA and the HSE regarding the report, and that it should not really have got to that point?

Mr. Phelim Quinn

I would say it is regrettable but I would also-----

Given that it has not changed substantially, in Mr. Quinn's opinion.

Mr. Phelim Quinn

Considering that we wanted to respect the whole issue of fair processing and due process, we did not comment throughout the whole process. I would not recognise what occurred as an exchange.

It looks bad to have two State bodies engaged in a type of discourse, or whatever one wants to call it, that reflects badly on the whole process. That is my opinion as Chairman of this committee. I accept Mr. Quinn's point that he did not-----

Mr. Phelim Quinn

This is our seventh investigation. During all our interaction with all the service providers that we inspect or review, we have established due process. That due process did not change for this investigation. It was exactly the same as in all our other investigations.

Ms Mary Dunnion

With regard to the question on a potential conflict of interest, we recognise in setting up any investigation team that there is such potential. In the case of our patient advocate representative, the many roles Ms Murphy had both in the HSE and the WHO were recognised immediately. We recognised the potential of that bias and put the controls in place. For example, Ms Murphy did not actively participate in the HSE risk management forums, in respect of which she had a key role. She identified that she was a member of the investigation team and, as a consequence, worked specifically on the investigation. We were confident that there was no conflict of interest in that regard.

The patient safety culture assessment had been conducted by the HSE prior to or at the beginning of the investigation. However, I believe the return rate of the survey on patient safety culture was approximately 8%. I may be incorrect.

Will Ms Dunnion explain that point, please, in simple terms?

Ms Mary Dunnion

Yes. The HSE was using a tool that would have required the staff of the organisation to answer specific questions. It is a recognised tool. There are multiple tools so the HSE obviously picked a specific one. One would want to be able to draw a conclusion and have a good response rate, with many staff returning their data. That was not the case with the HSE safety culture assessment. Therefore, was the tool used to lead change? We actually do not know because the response rate was so low it would not really give one any information.

One of the CMO's recommendations was that we should conduct a safety culture assessment in Portlaoise, and it was included in the terms of reference. In carrying this out, one will always nuance it by stating there are multiple tools and limitations to every tool, and they should only be used to bring about improvement. It gives information at a time but it is a tool to use. We commissioned an external entity well known for its work in patient culture assessment to conduct the survey for us because the authority would not have the skills or resources. There was a return rate of over 45%. We were satisfied that a significant number responded, giving a good indication of the culture of safety in the hospital. We used the mechanism to inform the questions we were going to ask and the areas we were exploring. We recognise it reflects a moment in time and that the tool should be used to drive improvement. As a consequence of that, we would have given the tool and its findings to the HSE at a national level once the survey was completed and the data were correlated.

Ms Mary Dunnion

It was in August 2014. We were disappointed to learn in one of our final meetings with Portlaoise in October 2014 that it had not received that tool and, as a consequence, would not have been able to reap the benefits of the findings of the tool. Significantly, the tool had indicated that there was not a strong culture of assessing safety and quality of services in the organisation. For example, there was no evidence that the senior management team collectively walked around the hospital to engage with patients and staff. The HSE has set a standard that complaints from patients should be replied to and resolved within a 30 day period but only 16% of complaints to Portlaoise hospital met that standard. That was a worrying finding because we were meeting patients who had not received any response to their complaints. It was even more worrying to find these issues were not discussed at management level, which meant arrangements were not in place to spot the problems arising.

I fear that the HSE views complaints as a negativity as opposed to an opportunity to learn what it is doing wrong and to fix it.

The report states that two months earlier the assessment had not been given but Mr. Quinn noted in his opening remarks that the hospital did not have a strong safety culture.

Mr. Phelim Quinn

That was an outcome of our assessment.

In regard to the 16% figure for complaints, is that why the report did not definitively express confidence in the safety of the hospital?

Mr. Phelim Quinn

That was not specifically an outcome of our use of the patient safety tool. We noted that an assessment of a range of indicators from the tool suggested there was not a strong culture of patient safety in the hospital. However, the patient safety assessment tool only provides an assessment at a point in time and should always be used to drive momentum in improving the patient safety culture in an organisation. The assertion that we could not definitively say that services provided in the hospital were safe was made as a result of a range of other findings.

Deputy Regina Doherty asked about the references in the chief medical officer's report to the availability of an emergency department consultant. Our report highlighted the fact that the emergency department consultant was only available for six hours per day, four days per week. It went further to state that the clinical governance arrangements in the emergency department, which covered surgery, medicine and paediatrics, were disparate, ambiguous and ineffective. We had concerns about the safety of emergency department services.

Why is it still open?

Ms Mary Dunnion

Changes have since been introduced. Emergency medicine consultant numbers have increased. Towards the latter end of our investigation, the group hospitals were developed and, while I acknowledge the groups are still in their infancy, the group CEO has formally streamlined the governance arrangements to ensure those who work in the emergency department are reporting to the clinical director in Portlaoise hospital. The bigger issue pertained to the nature and volume of patients passing through the emergency department. There was no evidence in the context of managing and planning a service that anyone was examining the data on patients coming through to find out the nature and extent of their conditions and the types of services they really needed. The hospital told us that 40,000 people attended but the HSE had a different number. We know the hospital was not critically investigating the types of patients and nature of services best provided. For example, it would be consistent with the recommendations on Ennis and Mallow to ask whether it operate a 24-hour emergency department or a different type of service.

Mr. Phelim Quinn

Members asked a number of questions regarding the experiences of patients and their families. We believe that the HSE has not carried out a patient experience survey. I understand from previous conversations with senior managers in the HSE that the survey is still under development. However, in line with practices in other regulatory bodies internationally, our business plan for this year includes a requirement for the development of better patient experience data to help us assess risk within the systems. The experience of other health and social care regulators internationally indicates that the work required in the area of patient experience has to be carried out in partnership with provider organisations. We have already started work in that regard.

In regard to the experience of the families and how they were treated, has that culture and practice changed? Am I correct to say that a new process was put in place automatically?

Mr. Phelim Quinn

It would be difficult to answer that question affirmatively.

I acknowledge it is not Mr. Quinn's specific responsibility.

Mr. Phelim Quinn

The key issue is the way in which some of the families involved in the investigation process characterised their experiences. Clear and basic communications skills are required in people on the ground and at various levels in the HSE. We believe additional training is required for people in-----

That was not my question. We accept all of that but I am asking whether the practices and culture which resulted in these families being treated in a certain way have ended.

Ms Mary Dunnion

In our last meeting with the hospital in October, there was strong evidence of a change in patients' experiences. We believe that was a result of the changes to the management structure in terms of having a visible presence on wards and engaging with patients, as well as increasing staff awareness of these changes. Progress has been made on the development of the risk management structure and dealing with patient complaints in a timely and appropriate manner and while nobody can give a complete assurance in this regard, there was evidence that change had happened.

Mr. Phelim Quinn

Subsequent to issuing the draft report we met the families who wanted to meet us on a number of occasions, more specifically in the days just prior to publication. There was ongoing communication and dialogue with families throughout that period. Clearly, the families were anxious about what was being revealed in the media and they wanted reassurance about our conduct of the investigation.

Some of the members' questions related to the tragic events that have come to light in respect of Cavan. In line with the terms of reference for the Portlaoise investigation, we committed to making an assessment under section 8 of the 2007 Act and to monitor services across all 19 maternity units in Ireland. In May 2014, the Minister requested us to monitor Cavan hospital in light of the three infant deaths that had occurred by that stage.

I will ask Ms Dunnion to give some detail about the sort of work in which we have been engaged with Cavan hospital in the ensuing months.

Ms Mary Dunnion

The first point, to nuance it, is that we see an urgent requirement for a maternity strategy to determine the type of maternity services being delivered in hospitals because the infrastructure and support structures of any hospital will dictate the type of service that should be there. We see that as a critically important component and, as a consequence, have again put in that recommendation.

When we were communicated with by the Minister for Health, the latter part of the terms of reference for the investigation into Portlaoise included the 19 hospitals. In the context of Cavan hospital, we have been dealing with the hospital and have had a full assessment of the three cases against the national standards for safer better health care and also how Cavan hospital has implemented the CMO's recommendations. The result is that they have demonstrated to us an assurance - we have not been in Cavan because it will be part of the monitoring of the 19 hospital - that there is matching against compliance with the national standards; their status of implementation of the recommendations of the CMO report; named accountability for implementation of those recommendations; and the timeframes in which they are to be implemented. We have established that with Cavan and we are monitoring that, as my colleague stated, in the context of our remit within HIQA.

We have taken what we found in May 2014 and used some of that to direct our inquiries in Portlaoise as part of an indicator of the lines of inquiry that we would take. We will be taking what comes from our findings in Cavan, our findings in Portlaoise and what we know should be in place, cognisant of the maternity strategy, and hopefully, much of that will be to the fore before the latter end of the year. All of that becomes part of the monitoring, the framework for which we have already begun designing for the 19 maternity hospitals with the intention of it being completed and published at the latter end of this year.

What is the difference between section 8 and section 9 investigations?

Mr. Phelim Quinn

A section 8 investigation is at one's own volition or at the request of the HIQA board. A section 9 investigation would be at the request of the Minister.

I asked about the recommendations on the patient advocacy service as against a patient safety authority and the other observation of there being no specific mention of staff shortages.

Mr. Phelim Quinn

I will take the issue of recommendation 1 and our call for the establishment of a patient advocacy service. Through listening to service users throughout this investigation, we are clear that they had lost confidence in what the HSE had in place. They were clearly saying to us that they needed the assurance of independent advocacy to help them navigate through both the investigation and complaints processes that follow on from adverse incidents or specific complains. It is on that basis that we have called for it to be independent. I appreciate that Deputy Regina Doherty referred to the fact that we have referenced the HSE here. Primarily, we believe it is the Department of Health that would take the lead in respect of the implementation of that particular recommendation.

When we look at patient advocacy in the context of a patient safety authority, that was initially articulated in the programme for Government. It is for the Government to determine what is within the confines of a patient safety authority. However, there is potential within a structure that embodies service improvement, quality improvement, patient advocacy, and regulation and oversight of services, to have conflicts of interest within the one body. I am not sure what happened in relation to the plans in respect of a patient safety agency, but there is a requirement here for an independent patient advocacy service as well as the regulation which is conducted by ourselves.

There are five other speakers indicating, including two Members who are not on the committee. I will start with Deputy Mitchell O'Connor, then call Senator Colm Burke and Deputies Seamus Healy, Lucinda Creighton and Sean Fleming.

I thank Mr. Quinn for his report.

I want to ask Mr. Quinn a straight question: is a woman who goes into Portlaoise hospital tonight to have a baby safe and will her baby be safe? He stated that the "volume of critical care activity within the intensive care unit of the hospital" is low and that staff "who do not have the opportunity to treat sufficient numbers of patients or carry out a sufficient volume of procedures run the risk of becoming de-skilled". Is that problem still there if that woman needs to go into intensive care?

I am baffled as to what the senior hospital management committee was doing. Mr. Quinn stated that "the hospital was not governed, resourced or equipped to safely deliver" the level of clinical services. What kind of personnel were on that senior hospital management committee? Were there doctors or nurses? Who was on that committee? Mr. Quinn spoke of a patient safety tool but surely if they are trained medical staff they can report, or do we need to have whistleblowers in every hospital to ensure the right thing is done? I thought that was what would be done with the senior hospital management committee or with the doctors or the nurses who were working in that hospital.

I am really concerned that Mr. Quinn spoke about the "quality, safety and experience of patient care in Portlaoise hospital", but then stated, "It must also ensure that where similar risks and deficiencies exist in other hospitals, these are addressed as a matter of urgency". I understand HIQA is looking at the other 19 hospitals. Cavan is on our radar, but where else does a mother have to go to risk her baby's health and to risk her own life before HIQA is called in? All staff on the ground are being paid; why are they not doing their jobs?

I thank Mr. Quinn for his report and presentation. I will go through a few matters because some members have touched on some of the issues that I wanted to raise.

Regarding the numbers in Portlaoise hospital, my understanding is that the number of deliveries in the hospital increased from approximately 1,000 a year to 2,300 over a short time period. Mr. Quinn referred in his report to the request for additional staff. To whom were those requests made? Mr. Quinn stated he received correspondence about it. Was there any increase in the number of staff in that time? I refer to nursing staff, medical staff and junior hospital doctors. What levels of increases were provided over that period and how was it responded to?

There is very much a focus on doctors and nurses, but one of my findings over the past 12 months is the number of administrative staff within the HSE who have ended up in jobs without ever having a job interview. Have we identified deficiencies in management across the board in this matter and is this one of the consequences of that process where staff end up in jobs without every going for a job interview? We will not promote a nurse up along the line without her going through a job interview, and we will not do it in the case of doctors, but are we doing so in the case of management? Has it arisen in reports HIQA has produced that there are serious deficiencies regarding the ability of management to make a judgment call and react to the needs of the staff who work on the front line, namely, the nursing and medical staff?

Recommendation 5 of the report is that the HSE "should ensure the appointment of a director of midwifery" in all the 19 units that do not have one. Has Mr. Quinn identified the number of units that do not have a director at this stage and have we set a timeline for them being appointed?

This issue needs to be examined.

The report found no evidence that the Health Service Executive nationally was proactively exercising meaningful oversight of the hospital. Who in the HSE is responsible at national level? One of the problems with it is the difficulty in identifying those with responsibility.

The report notes a failure to flag an increase in the number of claims in a particular area and an apparent absence of communication between the State Claims Agency and the HSE. Has HIQA recommended that the State Claims Agency address this issue at a senior level to ensure it will not happen again?

The third recommendation relates to the development of a national maternity services strategy. A report produced in 2003 set out the number of medical staff to be employed in maternity services. It recommended, for example, that the number of medical consultants in maternity services be increased to 190. The current figure is 104 whole-time equivalents.

None of the report's recommendations has been implemented. HIQA has produced another report. Will it also languish on a shelf? What mechanism is in place to ensure its recommendations will be implemented?

I thank the representatives of the Health Information and Quality Authority for their presentation and report. Is HIQA legally obliged to provide a draft report or is this part of its due process procedure? Were draft reports presented in all previous cases?

Politicians are frequently accused of not getting the right answers because they do not ask the right questions. For the purposes of clarity, can we be absolutely certain that no substantial change has been made to the report? Is documentation available showing what changes were made?

The background to this issue is a significant reduction in funding and staffing in the health service in recent years. The health budget has been reduced by approximately €4 billion, while staff numbers have declined by approximately 12,000 as a result of the moratorium on recruitment. HIQA's report states the Midland Regional Hospital, Portlaoise, did not have the proper governance procedures, resources or equipment in place to operate at this level. The budgets of many other hospitals have been reduced by up to 25%. Is there a link between recent budget cuts and the events that occurred in the Midland Regional Hospital, Portlaoise?

The report is shocking and in reading it one feels all sorts of emotion, from sadness and disappointment to frustration and anger. Failure and dysfunction occurred at many levels. The report begs the question as to whether the Health Service Executive is fit for purpose and capable of running a health service properly. Perhaps the delegates might a view on that issue.

Has the post of director of midwifery services been introduced in the other 19 maternity units?

The first recommendation relates to the establishment of an independent patient advocacy body. I fundamentally agree with Deputy Regina Doherty on this issue. How does one define "independent" in this regard? In recent years I have encountered cases where it transpired that independent patient advocates were fully funded by the HSE and certainly could not be described as independent. This scenario must not be repeated. If there is an independent patient advocacy organisation, it must be truly independent and not be linked in any way with the HSE.

On the recommendation for a national maternity strategy, is HIQA involved in discussions on this matter and does it have a preferred outcome?

I understand from the comments of the delegates that the recommendations made in this and previous HIQA reports cannot be enforced by HIQA or any other body. Is that the case and, if so, what actions would HIQA like to take to ensure the recommendations are implemented?

We will now take questions from non-members of the committee.

I thank the Chairman for giving me the opportunity to contribute and the team from the Health Information and Quality Authority for appearing before the joint committee and producing such a comprehensive report. To echo the sentiments of previous speakers, one almost experiences a sense of déjà vu when reading the report because much of it repeats what we have heard previously. Unfortunately, it is difficult to have any confidence that the recommendations made in the report will ever be implemented, although we could all be pleasantly surprised.

On the role of the Health Service Executive's internal national incident management team, why did this entity not take any action? It was fully aware of developments, had expressed a degree of concern and examined details of infant deaths in the Midland Regional Hospital, Portlaoise, in 2012? Why was no action taken? Is this unit or however it describes itself fit for purpose? There are definitely question marks hanging over it.

I have been raising the issue of perinatal mortality statistics for some time and note Senator Colm Burke did likewise in recent days. The figures appear to be entirely unreliable and inaccurate. The fact that reporting is voluntary means that clinicians and other hospital staff are not under any obligation to report infant mortality. We often hear that Ireland has one of the best maternity services in the world. I find this difficult to believe when it is so patently obvious that the statistics are not accurate because certain baby deaths are not reported and there is no legal obligation to provide such information. Should criminal sanctions be introduced for individuals and hospitals which do not report infant deaths?

What are the delegates' views on the possibility of introducing legislation on open disclosure? I understand a scheme of open disclosure has been piloted in the Health Service Executive. Has HIQA, through its regulatory and monitoring functions, noted any sign of success where this practice has been piloted? It certainly works in the United States and other countries and it would result in a much more transparent and accountable system here, one in which families would never again have to endure what families endured in the Midland Regional Hospital, Portlaoise, which beggared belief.

I echo Senator Colm Burke's question regarding who at a national level in the HSE is accountable, or should be held accountable. Who is responsible? We hear mention of regional, local and national levels, but somebody somewhere is responsible at all these levels. The question is: who is responsible? Is it possible for people to see accountability for the litany of negligence and cover-ups?

I thank the Chairman for this opportunity to speak at the committee. As a Laois person, I am sad that we are here again. I thank all the parents for the perseverance they have shown over the period, as otherwise we would not be here.

I have a few straightforward questions which were referred to earlier. Mr. Quinn said that he could not say the service in Portlaoise hospital was safe. By what date does he expect to be able to say it is safe? The Government said yesterday that it hopes to have some of the recommendations implemented by the end of the year, but 1,200 to 1,500 more babies will be born there in the meantime. Where is the position for patients going into that hospital? Surely HIQA cannot just ask it to draw up a timetable. That is not adequate; HIQA should be setting the timetable.

Second, the memorandum of understanding between the Coombe hospital and Portlaoise hospital is welcome, but will Mr. Quinn explain how that will integrate with the maternity unit and the rest of the Portlaoise hospital? There is an impression that the maternity unit and general management at the hospital have been operating on parallel tracks.

Will Mr. Quinn comment on the physical resources and structure of the ward in Portlaoise hospital which resulted in a situation in which mothers in labour were in the same room as mothers who had just suffered the loss of a baby? It is inhumane that this should have occurred. One mother was grieving while another mother about to enter that ward was afraid that what happened to that mother would happen to her next. I am not a female, but I know it would be horrific to be in that position. Perhaps the physical resources of the hospital were unsuitable.

The State Claims Agency has €1 billion provided in its annual accounts primarily for obstetric claims. Mr. Quinn will be aware of that. Up to €1 billion is provided, and that amount is contained in its published figures. When HSE delegates appear before the Committee of Public Accounts and we ask them about medical negligence, they tend to say that the State Claims Agency manages it and the agency sends the HSE the bill, which could be €60 million or €90 million this year depending on the outcome and the amount of time spent in court. They say it has nothing to do with the HSE and that it just pays the bill. That procedure has divorced the HSE from direct concern for, and day-to-day management of, cases. The HSE washes its hands of it the day the case goes to the agency, and the HSE sends a cheque every so often when it gets a bill. That demarcation is harmful. Lessons should have been learned. Is Mr. Quinn satisfied that those in senior management in the HSE, who knew about these life-and-death issues, are probably still in their positions? They should not be there; they should be on administrative leave today. HIQA should have had that recommendation in its report. Given that there are no adequate disciplinary procedures in place, that finding should have been recommended.

This investigation happened as a result of a "Prime Time" programme. Had those parents not gone to "Prime Time," would Mr. Quinn be here today? Where was HIQA's proactive role in this? Surely Mr. Quinn is not waiting for a Minister to telephone and ask him about a matter before he agrees that HIQA will carry out an investigation? HIQA is in place to do that without being asked. I am sorry to be a bit strong on Mr. Quinn in this respect, but he can understand the point. I am not in any way criticising anything, but HIQA could have been a bit more proactive.

On the point regarding the State Claims Agency, the committee has concluded a report on medical indemnity. One of proposals in that report relates to the HSE's policy around open disclosure. Deputy Fleming has made a good point. When will we see action and accountability in regard to all of this? If this is not about being patient-centred, and if "Prime Time" had not produced this programme, where would we be with this today?

Mr. Phelim Quinn

If I may, I will deal with the Chairman's last point first. I spoke earlier about some of the information we had received over a period, some of which was received from parents. That was what prompted us to initiate a proactive assessment of the governance arrangements within Portlaoise hospital. I am not saying that was the only indicator, but it was one of the indicators, and it certainly would potentially have led us to some of the conclusions we made in the investigation report. However, that would have been under section 8 of the Act, because it would not have been a statutory investigation in terms of monitoring against the national standards.

With respect to proactiveness, I would say - this is not an excuse - that HIQA has been in existence for eight years. It came into existence in 2007, and since then it has conducted seven statutory investigations. The vast majority of HIQA's activities within the health care system in Ireland have been focused on investigation work. Therefore, most of the resources of HIQA have had to be pulled into what is a reactive form of regulation within our health care system. I came to HIQA two years ago as director of regulation, and one of the things we have tried to do is to initiate a more proactive programme of monitoring against standards, because we believe that not only will that elicit information from our health care system, but it has a better chance of driving improvement, as opposed to a situation in which we are continuously reacting to crises within our services.

Does a culture of being more proactive than reactive exist within the HSE? That is the key question. We can deal with issues in our committees, but if that culture has not changed, or is not about to change, then we are beating our heads against a brick wall.

Mr. Phelim Quinn

In answer to the question of when the services will be safe, in any health care system it is the responsibility of the provider within that health care system to be compliant with the national standards and with all other standards. It is the role of the regulator to make an assessment against their compliance. On the question of when the services will be safe, unfortunately, I believe that is a question for the HSE. The HSE has to tell us when it believes they will be safe, and we will at that point try to make some form of assessment of assurance on that particular statement.

Does Mr. Quinn not see HIQA, as the regulator, as having a role in saying that services are unsafe or safe?

Mr. Phelim Quinn

Absolutely, but within any health care system, when national standards are endorsed by a Minister and disseminated into the system, primary responsibility for adherence to those standards has to sit with the provider of that service.

On the question of the memorandum of understanding between the Coombe hospital and Portlaoise hospital, Ms Mary Dunnion has outlined some of the measures that have started to take effect and that have resulted in some level of improvement in maternity services in Portlaoise hospital. However, I believe our obstetric colleagues within the investigation team believe there is a way to go here, because that memorandum of understanding enables clarity in relation to patient pathways. There is the question about which pregnant women avail of services within Portlaoise hospital and which women presenting with a higher risk are referred on to obstetricians and midwives within the Coombe hospital. Also, there is the question of learning across the two sides and the rotation of both obstetric staff and midwifery staff across the two sides to maintain competence within their particular disciplines.

Deputy Fleming asked about the physical resources in Portlaoise hospital, and he asked a specific question about the physical environment and the experiences of those who had been bereaved. Ms Mary Dunnion might like to reply to that question, as she was closer to dealing with that specific issue.

Ms Mary Dunnion

It was sad to listen to patients' experiences. It is good to know that controls have been put in place in Portlaoise hospital to provide that if a woman has that tragic event, a single room will be provided where she can be managed and cared for. A bereavement counselling service has be put in place in the hospital which will help in that situation, but that facility and that service were not provided until those tragic events came to the fore.

We were asked whether Portlaoise hospital was safe. I do not think anybody can say that any hospital is safe, because risk is inherent in all clinical services. When we looked at maternity services we relied very much on our obstetric experts, and Professor Jimmy Walker was the main expert. He would have said that the majority of patients going through the maternity services in Portlaoise hospital are safe because they are normal healthy ladies expecting a baby and delivering a baby, and that the concern arises where there are patients with risk. As my colleague outlined, we need to be able to transfer that patient in the right time and manner to another hospital. We see the memorandum of understanding, that network with the Coombe hospital, as being the essential determinant of that.

It will not get rid of all risks, as there is always risk in hospitals.

In the context of critical service provision, by virtue of its layout, the intensive care unit is not conducive to providing a service to the level one would expect in 2015. There is no confidentiality or privacy for people. It is a poor facility. The anaesthetists, who are primarily in charge of a ventilated patient, do excellent work. In Portlaoise hospital they moved patients very quickly when they needed to do so, but the question is whether the service can continue in that way. From the point of view of HIQA's investigation, the answer is no. The infrastructure is not good and the clinical staff would identify that they need to get the pathways right. The recommendation about having hospital groups is not about diminishing the role of any hospital but ensuring the pathway for patients is safe. The same applies to surgical services. There were just not enough major cases in Portlaoise hospital to ensure the surgeon remained competent. It is not a matter of questioning his ability. It is like anything else - the more often one does something, the better one becomes at it. The hospital did not have a sufficient volume of cases. It dealt with 6,000 surgical cases per year, but only 49 of these were major. It is a tiny number of cases to ensure sustainable delivery of the service. These were not the findings of the investigation team only; they were also the findings of the HSE which reviewed the service and made the same findings. Therefore, in the context of accountability, the issues were known and it was a source of huge concern for our investigation team that they had remained unaddressed. That was the position as we had found it and reported accordingly.

If a woman ends up in the intensive care unit of the hospital tonight, will she be looked after? Will she be treated in it or moved on within the recommended time limit? Sometimes this does not happen because a woman's blood pressure increases suddenly and the baby must be delivered immediately. How can HIQA guarantee-----

Ms Mary Dunnion

I cannot guarantee anything.

Politicians have marched on the streets in an effort to keep open intensive care units, without professionalism or proper procedures being followed in these units. We must all listen to what HIQA is stating in that regard.

Ms Mary Dunnion

Yes. The recommendation is that, irrespective of whether it involves a hospital or a group of hospitals, it publicly state the types of service it has been equipped and resourced to provide and what it can safely deliver.

In the context of the numbers of staff available in the maternity unit, additional staff have been put in place. This very action suggests staffing levels were inadequate. However, when the investigation team looked at staffing levels in the hospital, it was unable to ascertain what were the actual staffing levels in the maternity service or the general service because it was given a global figure for the whole hospital. We were not able to determine what were the staffing levels in different areas. More importantly, no one can tell us what the actual staffing levels in a maternity hospital should be. That is why in 2013 we emphasised the need for a maternity strategy to begin to identify what the staffing levels should be because in the absence of such a strategy, it is speculative. We know that the hospital was challenged to keep its staffing levels acceptable, as determined by it. There were several reasons for this. If a member of staff left, for example, it was almost impossible to obtain sanction to recruit. If sanction was given, it was a protracted process and took ages to get someone new into the system. As a consequence, the hospital was reliant on agency staff all of the time. That raises issues because different people are reporting for work, they have to learn the ropes, be supervised and so forth. There were resource issues at Portlaoise hospital which were not unidentified. In fact, the hospital had been identifying them continuously at a local level and had escalated them at regional and national level. They were then de-escalated regionally again. There is a plethora of documentation which shows this to be the case. All we know, to address the issues identified and make the maternity service safer, staffing numbers had to be increased. This was done in 2014.

Ms Dunnion says there was a plethora of correspondence. Who was the correspondence between?

Ms Mary Dunnion

It was at all levels of the HSE. Correspondence went from local to regional to national level and back to regional level. There was continuous correspondence on the issue. Adjustments were made to the numbers working, but staff were leaving and it took ages to get others in to replace them. It was a never-ending cycle.

The key time was between 2003 and 2009 when there was a huge increase in the number of deliveries. Was the response during that period appropriate? I know that we have now responded, but that period predates any of our major financial problems nationally. Surely there was someone in charge at managerial level. How come there was no response at that stage?

Ms Mary Dunnion

The need for staffing was certainly identified by the hospital. Members of the investigation team identified that the rise in maternity rates was a national issue; it was happening in all maternity hospitals across the country. We do know, however, that in terms of recruitment, the response was slow. Even if posts were sanctioned, it took a long time to recruit staff. This, coupled with the rate of staff leaving, meant that the hospital was on the back foot in the context of staff numbers.

That suggests to me that when the health service identifies an increased demand, it is too slow in responding, regardless of the service in question. I know of a person who worked in the health service in the United Kingdom. A sudden increase in demand was identified and within six months a new clinic had been opened. The person in question came back to Ireland to work and also saw an increase in demand, but it was ten years before a clinic was opened.

Ms Mary Dunnion

We could not find any evidence to suggest the systems in place were able to respond as quickly as was required.

In terms of the difficulties encountered, when Ms Dunnion refers to recruitment, is she speaking specifically about midwifery services and obstetrics? Was there a problem in attracting personnel or was it just the case that the process was laborious and long-drawn out? What was the main reason for the inability to recruit senior clinicians and midwives?

Ms Mary Dunnion

Recruitment was not conducted locally because it was not within the powers of the hospital to do so. There was a national recruitment process. It was reported while we were on site in Portlaoise that the recruitment process was a long, drawn-out affair.

The issue is with the recruitment process, as opposed to people not being willing to work in the hospital. Is that correct?

Ms Mary Dunnion

Yes. That said, there is obviously a difficulty in attracting staff to training positions. Lots of the more junior doctors were not on a training programme which, in itself, did not make it attractive to apply.

Mr. Phelim Quinn

I will try to respond to a number of the other questions posed.

Deputy Seamus Healy asked about due process and the requirement that HIQA provide a draft report. As our due process is established, we always provide a draft report for the director general of the HSE and those identifiable within the report for their comments. We always afford individuals the right to look at what has been written.

There was a question about the director of midwifery services and the timeline for-----

On the first point, was any individual named in the draft report?

Mr. Phelim Quinn

No. It is not within our remit to name individuals in a draft report.

The role of the director of midwifery services is dealt with in recommendation No. 5 made in the report. We were asked about the number of directors of midwifery services in maternity units and the timeline involved. The timeline is specified within the recommendation. We have asked the HSE to make sure there is recruitment to fill the posts by September. We cannot say, definitively, how many units have a director of midwifery services, but we are asking that all units have such a director in place by September to provide leadership.

A number of questions were asked about accountability within the HSE.

In any organisation such as HIQA, ultimate accountability sits with the accountable officer and the executive of that organisation. We reflect that is the same within the HSE nationally.

Does HIQA make recommendations to the HSE?

Mr. Phelim Quinn

All these recommendations are made-----

Outside the recommendations of the report in terms of accountability.

Mr. Phelim Quinn

No, we have not done that. I do not believe it is the role of HIQA as a regulator to identify individuals. There are accountability structures in place nationally and it is for those that hold the HSE to account to act in that regard.

Mr. Quinn has said it is not within HIQA's remit to name individuals. Is that why we do not have names in the report? Members have mentioned that it is like being on the vicious roundabout. It is about ensuring patients, mothers-to-be and families have confidence in the service. I am not looking for a name, but if there is no accountability in the system, how can change be implemented to ensure there is confidence and accountability? If HIQA, as the independent regulatory body, cannot do it, who can?

Mr. Phelim Quinn

There are accountability and reporting relationships from the HSE into national structures. There is a requirement here for them to be addressed in that manner. However, in respect of recommendation 7, and it is the first time we have had to do this, we commended these recommendations to the Department and to the HSE for implementation. We have also asked specifically for people to be named as accountable for the implementation of these recommendations.

Was the issue of managerial skills evident in that matter? We are all identifying a lack of skills, for instance nursing or medical skills, but has poor judgment been identified in the placing of 1,500 people into jobs on the administration side without an interview?

Ms Mary Dunnion

The investigation team found was that at a local level the management was floundering and that it did not have the arrangements in place to ensure that the service was being managed to ensure quality and safety. In the report, we state that this was known and was not addressed.

That is the point. It is very clear in the report, from my own reading of it, that we did know who knew what was going on. If there is no accountability, we are just providing window-dressing and playing along with the system. Arising from the recommendations, would HIQA advise that the HSE and the Department should come before the committee and outline why they have not implemented the eight recommendations or when they are going to do so? Are they going to come back to HIQA and say they will do it? Mr. Quinn has said in respect of seven of HIQA's statutory reports that there have been deficits in some of them in terms of the findings. Am I right in saying that?

Mr. Phelim Quinn

Yes.

If that is the case, who is accountable?

Mr. Phelim Quinn

The key issue is that this was a statutory investigation commissioned by the Minister under section 9 of the Health Act. We conducted this investigation as the statutory body charged with that function. We completed that investigation and provided the Minister with the results. We believe the enactment of the recommendations sits primarily with Government. As an instrument of Government, maybe there is a requirement for the involvement of this committee as well.

Would Mr Quinn favour the amendment of legislation to extend HIQA's remit to include monitoring the implementation of reports?

Mr. Phelim Quinn

Internationally, in most countries the regulator does not have the responsibility to oversee the implementation of recommendations. In other countries, there is a commissioner of services who takes on board the recommendations and requires under commissioning arrangements that a provider organisation carry out the implementation of recommendations. It would not always be in the remit of the regulatory body.

I ask for clarification regarding a matter I raised at the outset. I am still not clear regarding the relationship between the Minister of the day and HIQA. For instance, the Minister had said he wanted HIQA to pay particular attention to maternity services in Cavan in addition to the investigation it was already undertaking into the Midland Regional Hospital in Portlaoise. There seems to be a difference between the written communication of 14 May 2014, which was a request, and a formal order. Is there such a distinction? Is there such a situation at present? In her response, Ms Dunnion said the focus on Cavan was only in the context of all 19 maternity units. Although HIQA has taken possession of information on the first three cases, no reports have been published. I had asked when this was done and whether it had been done prior to the preparation of the draft report, because my understanding from inquiries I made was that it had not.

Ms Mary Dunnion

Communication and information-sharing between HIQA and Cavan hospital has been going on since May 2014, so it would have preceded any draft report because we did not finish our investigation and the draft for due process was issued in February 2015. We have been dealing with Cavan hospital in the interim. Deputy Ó Caoláin is correct that we do not have the reports of the individual inquiries into the cases. They are to be given to us once produced. However, we have received the controls they have put in place as reported to us in the context of those particular cases, excepting that the full report is not available. We have taken that information and are in continuous communication with Cavan General Hospital. We used that information to inform some of our investigation into Portlaoise, but, more importantly, to inform our investigations into the total of 19 hospitals that we will be reviewing. It is an ongoing process, which started in May 2014.

Was it a formal order and request?

I am conscious of time.

Mr. Phelim Quinn

No formal order or request was made to conduct an investigation in Cavan. Our formal order was to conduct an investigation into Portlaoise. However, in our terms of reference we recognise the requirement to do a wider review under section 8 of the Act within all 19 services. We recognised the Minister's concerns at that time and initiated-----

Did the Minister not write to HIQA in May requesting that?

Mr. Phelim Quinn

Yes, there was communication between the Minister and HIQA.

I seek clarity on the difference between sections 8 and 9 in the 2007 Act. Section 8 states that an investigation can be carried out at the request of the HIQA board.

Mr. Phelim Quinn

I apologise. I misled the committee earlier and should clarify that. In summary, section 8 of the Act provides HIQA with the power to monitor against nationally mandated standards. That refers to the proactive report HIQA would undertake. Section 9 of the Act has two parts, one that enables the HIQA board to determine whether or not there is significant risk to the welfare or life of individuals and therefore initiate an investigation at the request of the HIQA board. A further part in section 9 enables the Minister of Health to initiate an investigation.

In the legislation, the board of HIQA could establish an investigation with the same powers it has under the Minister's request. Is that the case?

Mr. Phelim Quinn

Yes.

It can do the exact same thing under section 9, requesting the board to-----

Mr. Phelim Quinn

Absolutely. For example, five of the seven investigations conducted by HIQA have been at the request of the HIQA board, not at the request of the Minister of the day.

In the context of Portlaoise, while I am not saying that HIQA had the resources to do it, was there not enough cause for concern in the initial investigations since 2008?

Were board members not concerned enough to request HIQA to carry out an investigation, as, ultimately, it was the Minister who requested it to investigate the matter?

Mr. Phelim Quinn

HIQA had a level of information to it, but I do not believe the information it held at that point would have reached the threshold. However, the concerns of the then Minister were based on the report of the chief medical officer that had been published.

I thank the delegates from HIQA, Mr. Quinn, Ms Dunnion and Mr. Whelan, for their co-operation. I thank committee members and other Members of the Oireachtas for their engagement in the discussion. As I stated, our focus must be on the parents, families and children whose experience of the health service was very negative. It is important that we work collectively to resolve these issues to ensure patient safety is of paramount importance.

The joint committee adjourned at 4 55 p.m. until 9.30 a.m. on Thursday, 14 May 2015.