HIQA Investigation into Midland Regional Hospital, Portlaoise (Resumed): Health Service Executive

I welcome to our second session today the representatives from the HSE, led by the director general, Mr. Tony O'Brien, Ms Laverne McGuinness, deputy director general, Dr. Colm Henry, clinical adviser for HSE acute hospitals, Professor Richard Greene, director of the national perinatal epidemiology centre and professor of clinical obstetrics, Dr. Philip Crowley, national director for quality improvement for the HSE, Dr. Susan O'Reilly, CEO of the Dublin-Midlands hospitals group, Mr. Liam Woods and Ms Angela Fitzgerald. I thank Mr. Ray Mitchell for co-ordinating on this and thank the representatives for attending.

Our meeting today is a continuation of our examination of the HIQA report and its findings in regard to safety, quality and standards of services provided by the HSE to patients in the Midland Regional Hospital in Portlaoise. This morning, we met parents involved and it was one of the most emotional meetings I have had as Chair of this committee. Again, I wish to thank the parents who attended and presented to the committee this morning.

I welcome our witnesses this afternoon and draw their attention to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the 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 a 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 or 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 House or an official either by name or in such a way as to make him or her identifiable.

I call the director general of the HSE, Mr. Tony O'Brien, to contribute.

Mr. Tony O'Brien

Thank you. The normal convention is that I would submit a written statement and then proceed to read it out here. I have elected not to do that on this occasion, because I do not think it would be the most appropriate way to proceed, but I do wish to make some remarks.

Any loss of a baby is always a tragedy, and where that is an avoidable loss-----

I wish to point out to Mr. O'Brien that the families who were present this morning are now in the Visitors Gallery.

Mr. Tony O'Brien

Thank you. Any loss of a baby is always a tragedy and this is doubly so if the loss is avoidable. It is also true that any indefensible behaviours, lacking in basic human compassion, multiply that tragedy and cause unimaginable trauma and hardship. I want to make it clear that nobody is here today with a view to defending any of that.

As director general, I have made the organisation's and my personal position crystal clear on the central issue of compassion in care. I have communicated to all staff in the organisation that the required standard, particularly when things have gone wrong, is that we treat our patients, our clients and their families as we would wish to be treated ourselves and as we would wish our relatives to be treated. This message has been communicated to leave everyone in our wider health service in no doubt of the expected standard of behaviour.

In other jurisdictions where there have been failings in showing compassion such as in neighbouring countries, one of the approaches has been to seek to reinvigorate the capacity of leaders in the relevant disciplines to reinvigorate compassion in providing care. We will follow that example by inviting the Florence Nightingale Foundation which has been performing this function recently in the National Health Service in the United Kingdom to provide exactly that kind of enablement training for nursing, midwifery and interdisciplinary leaders throughout the health system and in all settings, not just acute services.

There are also very significant concerns about the way issues of risk were escalated and responded to within the health service. The HSE is instituting a formal disciplinary investigation into the issue of risk escalation and response and the issue of the absence of compassion in providing care. It will utilise external investigators who have never worked in the health service to carry out investigations in accordance with fair procedures and the disciplinary procedure in order that the requirement for accountability can be served.

In addition, there are concerns about governance, particularly in some of the smaller settings and their linkages with larger settings. As a result, we have commissioned Mr. David Flory, CBE, the outgoing chief executive of the Trust Development Authority of the NHS, to begin a process of examining these issues in some of our smaller services, in particular, and especially those involved in maternity services. That process will be extended to all services. This is not just about accountability. It is also about how we ensure these things do not recur and how we ensure services are improved to the greatest extent possible.

As the committee is aware, I was asked by the former Minister for Health, Deputy James Reilly, to be the first and I believe the last director general of the HSE. I took up the role on a designate basis in August 2012. At the time it was made clear to me by the then Minister that one of the reasons he had appointed me was that I had for some time been one of the chief critics of the way in which the HSE had been set up and the way it functioned, which was particularly centralised. It was my view then that the organisation was too big to function in its current construct. My experience of working in BreastCheck and CervicalCheck under the national cancer control programme led me to believe it was necessary to create different levels of governance in order to improve the way the whole system delivered. I, therefore, took the job on the specific basis that I was being asked to lead on that programme. In other words, I would not have taken the job in order to maintain the status quo in an organisational sense. In that context, the programme in which we are engaged of creating hospital groups, on the one hand, and community health organisations, on the other, is the central way in which we are improving the health service, not just for now but into the future, in order that decision making can take place, in the hospital sector in particular, within the context of governance constructs of arrangements of hospitals that make both geographical sense and bring management closer to the delivery of care and enable much of the networking and reorganisation of services to take place in a planned and coherent way. Similar issues arise in community health organisations, but I will not dwell on that aspect.

Contrary to what has been reported, the then national director of acute hospitals, Mr. Ian Carter, in response to the "Prime Time" programme on the Midland Regional Hospital in Portlaoise, immediately went to the hospital and engaged in a process which led to the appointment of a specific manager and a director of midwifery for the maternity services and the acceleration of a performance diagnostic. I also accelerated some of the things about which we had previously talked at this committee in terms of changing the structure of quality functions within the organisation and the relationship between these quality functions and the divisions with line responsibility for services.

In addition, after difficulties surrounding the competitions to fill the chief executive posts relating to those hospital groups, in the latter part of the second half of last year I took the decision to move the most effective talent we had available in order to ensure that life was breathed into the groups.

In that context, Dr. Susan O'Reilly, who is accompanying us today, was recently appointed as chief executive of the Dublin-Midlands hospitals group, the relevant group in this case. Dr. O'Reilly agreed to move from the national cancer control programme in order to take up her new role. The fact that I asked her to do so and that she accepted is a statement of our commitment to make the Dublin-Midlands hospitals group as effective as it possibly can be in addressing all of the concerns that exist.

As I have stated previously, we accept all of the recommendations contained in the HIQA report. It is true that we have concerns about some of the process issues relating to who did and did not have an opportunity to comment on the report. I will not dwell on that matter now but I will be happy to answer questions in respect of it if members wish me to do so. However, there are some continuing errors of fact, one of which I have referred to, namely, the notion that nobody at national level responded in any way to the concerns that emerged on foot of the "Prime Time" programme. I have explained to the committee what happened there. It is suggested in the report that it was the HSE which took the decision that Portlaoise should remain a model 3 hospital. As members are aware, the Government policy decision in this regard was announced at one of the committee's meetings in 2011.

The HIQA report also lacks any reflection of resource issues. In reference to resource issues I wish to make clear that these do not explain, excuse or minimise the importance of matters such as compassion and care. They do, however, have a significant impact on the way health services are delivered. The HSE is obliged to work within specified resources. During the years in question, those resources were diminishing significantly. I wish to provide the committee with a couple of examples of why resources are key in terms of quality and safety. As discussed last week - I believe it was Senator Crown who raised the matter - and in the context of international comparisons, we should not have 120 obstetricians, we should have 240. Making the shift in this regard would cost €24 million in a full year. Of course, such a shift could not be achieved in a full year. We now need to appoint directors of midwifery. Our decision to appoint one in Portlaoise was somewhat innovative but it has proved successful and is now recommended by HIQA. Appointing directors of midwifery to an additional 14 units would not be without resource implications.

Much is said about the HSE either being or not being a learning organisation. The term "learning" is important but many of the entities which have the characteristics of being learning organisations invest significantly in terms of time and effort in order to learn. If we were, for example, to release all members of our staff for just one day each year in order that they might focus on learning activities in the context of our care service, the cost of replacing them would be €9 million. If we wanted to release them from duties for a week, it would cost €63 million. Staff releases, training, etc., were among the first things that went when the financial emergency occurred. The HSE has not yet recovered to the position whereby it has the financial resources available to allow it to reinstate them. There would also be a significant cost involved if we were to bring all of our emergency departments, EDs, to a point where they would have full 24-7 consultant cover.

While the points I am making are not in any way being put forward as excuses in the context of issues relating to compassion, they are an important part of the overall matrix when it comes to quality and safety within the service.

We had a discussion with HIQA about that, mostly because its terms of reference require it, under the legislation, to take into account both Government policy and the resources available to the executive, which it elected not to do.

In terms of the future I am absolutely convinced that the course we set out on two and a half years ago to create hospital groups, to change the way the organisation was structured and to remove the regional layer is a journey that, when complete, will have an enormous impact on the quality of the services we provide, on the way we relate to our staff and on almost every aspect of the delivery of health care in Ireland. That is a journey that I intend to complete for those reasons.

It is often said, and I agree, that this report is a watershed. I have an additional reason for saying this. It is because it has a huge impact, and will have a huge impact into the future, on the interplay between Government policy and funding and on the role the HSE must play in interpreting those issues when it decides how services will be provided. This is written fairly large in the report and represents a variation on previous practice. Given that the report has been issued, it has a fundamental impact on how the health service will have to operate in the future.

As we did this morning, we will take groups of three. I would appreciate it if members could be concise with their questions rather than giving Second Stage speeches. I call Deputy Kelleher.

How many minutes do we have?

Up to ten. Non-spokespeople have up to four minutes.

We welcome Mr. O'Brien again. We know there are restrictions on what an Oireachtas committee can say and on discussing issues in great detail, which arose as a result of the Abbeylara judgment, so we will keep our comments generic. Mr. O'Brien and his colleagues are the collective leadership of the HSE and have responsibility for the HSE.

In our detailed discussion this morning, Ms Róisín Molloy spoke of her experience and that of her husband. We also heard from Ollie Kelly and Amy Delahunt and from Patient Focus on the issues in Portlaoise. In her closing testimony, Ms Molloy said: "We were treated with disdain. They hated us." It was powerful because she had outlined the efforts she had made as an individual from the day her baby was born in Portlaoise on 24 January 2012, culminating in a continual effort to get to the truth of what happened and to ensure it would not happen to others. We also heard that many people had told Ms Róisín Molloy during her interaction with the HSE that this had not happened before and would not happen again. Unfortunately, just last Wednesday, the Minister heard many testimonies from many people that things did happen before, such as a lack of compassion in dealing with people who had issues relating to their health care and when they made subsequent efforts to find out the truth of what happened. It has been happening for some time, Mr. O'Brien, and it is an issue we would like to be addressed in a meaningful way.

Mr. O'Brien spoke about a watershed moment, and HIQA last week said this was a watershed report. It is a very detailed report and makes for harrowing reading in parts. It is not very complimentary of the HSE in general. Mr. O'Brien said he takes issue with some of the findings in the report but not with the recommendations, which I assume he accepts. I will go through some of the areas referred to in the report.

On page five there is reference to weak oversight and inaction. On page eight it states there was "no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks there". On page 18 it states there was "an ongoing failure on the part of the HSE to evaluate the services provided at Portlaoise Hospital against the risks and recommendations identified in previous local and national reviews and investigations conducted by the Authority and HSE". It further states: "Sufficient action was not taken by the HSE at national, regional or local level to address these issues." On page 46 it states: "Whatever the rationale for any decisions underpinning the model of care to be delivered at Portlaoise Hospital, it would be expected that the HSE would ensure that the hospital was safely structured and resourced to provide the care it was delivering." I would appreciate Mr. O'Brien's response to that comment in the report. He made reference to the fact that it was a policy decision that Portlaoise was retained as a model 3 hospital. He said that was a political decision announced here at the health committee. At what stage does policy override patient safety? If a decision is made at policy level for something to be done and the HSE is charged with responsibility for implementing that policy but if patient safety is an issue, at what stage does the HSE say that it cannot deliver on that policy? I would like some clarity on that issue also.

The report states: "In 2013, [HIQA] recommended that the Department of Health and the HSE would work together to conduct a review of the national maternity services and develop and implement a National Maternity Services Strategy." It further states: "At the time of finalising this report 19 months since the Authority published this recommendation, a national maternity strategy has not been developed or significantly progressed. The Authority considers the delay in developing and publishing a national maternity strategy unacceptable." I know that a review is currently being carried out, as announced on foot of the draft report being presented to the Minister.

It seems at every level that the efforts by the families - we must always centre this back on the families - to try to get to the truth of what happened in their circumstances were stonewalled and barriers were put in place. I do not say that lightly; I say that because I genuinely believe the families' testimony to us and that other families I have met and listened to felt that at every level the HSE was very slow in its efforts to come forward with information. We have some testimony from families, particularly from Amy, Ollie, Mark and Róisín, who said they were basically informed that they could get the information through a freedom of information request. We know there is not yet a policy of open disclosure in the HSE services across the country but at the very least one would think there would be an inherent compassion in an organisation like the HSE to help the families get through their grief, but it seems right through all this that the opposite was the case.

I find it hard to accept, having read through the full report, that patient safety was not on the agenda, as stated in the report. Patient safety was almost never on the agenda in terms of discussions at national level even though, by any stretch of the imagination, everybody who was in a senior management position in the HSE would have or should have known at that stage that there were major concerns in Portlaoise hospital and that they were being expressed to senior management at both local, regional and national level. The report by HIQA and the statements by the families indicate there was a very slow response or, one could say, no response in many cases to the alarm bells that were ringing. We talk about a systems failure and the fact that red flags were not being raised but, as I said to Mr. O'Brien last week when we were discussing other issues, alarm bells were sounding off everywhere at every level. The State Claims Agency was writing in this respect, the INMO was lobbying for extra resources and patients who had terrible experiences and tragic outcomes were consistently contacting the HSE but almost to a person they were consistently being denied an opportunity to fully find out what happened.

If the families who had tragic experiences in Portlaoise hospital had been embraced by local, regional and senior management, happier outcomes could have come about for those who interacted with the health services at a later stage.

Mr. O'Brien referred to a watershed. In 2008 there was a report on the provision of care of Rebecca O'Malley. Again in 2008, there was a report on the investigation into the provision of health services to Mrs. A by University Hospital Galway. In 2009 there was a report on the investigation into the quality and safety of services in the Mid-Western Regional Hospital, which is known as the Ennis report. In 2010, there was another report on Mallow hospital, referred to in this report as Mallow. In 2012, there was a report on the investigation into the quality, safety and governance of the care provided by Adelaide and Meath Hospital, Dublin incorporating the National Children's Hospital, and in 2013, there was a report on the care and treatment provided to the late Savita Halappanavar.

The constant difficulty we have is that these HIQA investigation reports made a number of findings and recommendations for the relevant hospitals, and the Health Service Executive, HSE, nationally, which should have been used by all health care services as a learning tool to inform and improve practice and drive service quality and safety.

The Deputy is on eight minutes now.

We have had six reports to date, and we always believed that the recommendations in those reports were to be implemented across all health service provision in the areas they affected. It is difficult to accept that this is a watershed. It will be a watershed, a defining period, if there is full and prompt action.

I do not want to lay all blame at the door of the HSE. There is a responsibility to ensure that we provide the adequate resources, but at some levels it had nothing to do with resources. Basic humanity and compassion should never be a resource issue. It is about natural courtesy. A willingness to embrace people and help them through their trauma and grief does not cost anything. A phone call or to return a phone call should not cost a lot, as opposed to families waiting weeks to receive phone calls. Having to consistently beg for information is appalling and is something for which no resourcing issue could ever be used as an excuse.

In terms of reporting and the National Perinatal Epidemiology Centre, NPEC, in Cork, it seems to be the case that we still do not have a proper reporting system in place for infant deaths. Why is that the case? We have a number of statutory agencies that report infant mortality and behind the figures nationally we should dig a little deeper to ensure we are not missing some other problems in our health services in general.

Deputy, your ten minutes are up.

In terms of inquests and the HSE, I have spoken to some families who said, and some of the families present stated it also, there was always an encouragement by the HSE to initiate court proceedings and seek compensation. The view that could be drawn is that by doing that, the very minute papers are served on the HSE, any internal investigations are suspended for that duration. Also, if one goes to the steps of the court, very often the HSE will pay out compensation without admission of liability, and therein the issue is parked forever and a day. Should we move swiftly to an open disclosure policy and ensure that the report and its recommendations are implemented quickly?

Finally, does Mr. O'Brien honestly believe that the HSE can implement the recommendations in the report or does he believe that some other outside agency or oversight body should be established to ensure that the HSE can conduct its affairs and bring about an orderly implementation of the recommendations, in view of the fact that many parts of the previous six reports were ignored?

My questions and remarks are directed at Mr. O'Brien.

However, I would like it to be noted that they apply to everyone in a senior management position in the HSE and it is a shared and collective responsibility.

To what specific references, in what one is told is a largely unaltered HIQA report on Portlaoise hospital did Mr. O'Brien object? Does he still hold to those objections? He felt strongly enough to issue the threat of legal action on the presentation of the draft report. He is on record as stating here last week, as did the Minister for Health, that he accepts the recommendations contained in the report. However, will Mr. O'Brien refer members to the sections of the report he felt so strongly about that, as I have stated, he issued the threat of legal action to suppress that report? Will Mr. O'Brien also confirm this is not the first time that he or the HSE have endeavoured to suppress the detail in respect of the Portlaoise babies scandal? Is it not the case that Mr. O'Brien or the HSE sought to suppress the "Prime Time" programme broadcast on 31 January 2014? Is it not the case that it was when, as with HIQA, RTE showed stoicism and refused to buckle under threat of legal action to close down the programme and proceeded with it that Mr. O'Brien then withdrew his threat? Was it not on the back of that stance by RTE, in light of the fact that the programme was going to proceed, that the HSE issued an apology to the parents concerned just before the broadcasting of the programme?

Of the evidence presented to the joint committee this morning, one of the areas of most concern for me was that it was reported to members that two senior post-holders of the HSE met Mark and Róisín Molloy in October 2013. The proposal was to discuss the implementation of the 43 recommendations in the report concerning the tragic loss of their young son, Mark. However, members were advised they were told that the two senior figures were only there to listen, which does not equate in my mind or in theirs or in that of any other member of the joint committee who heard their contribution this morning with discussion in any shape or form. I ask Mr. O'Brien to comment on that.

Deputy Mary Mitchell O'Connor took the Chair.

Let us look at what the HSE has to say on its own website about itself and the commitment to what one can expect from the HSE. Under the statement "What you can expect" from the HSE regarding dignity and respect, it states, "We treat people with dignity, respect and compassion". I do not believe any of those could be ticked after listening to the case presented this morning. Under safe and effective services, the HSE claims "We provide services ... in a safe environment, delivered by [competent, skilled and] trusted professionals". It is the case across the HSE and across all the health delivery systems that indeed we have highly competent, skilled and trusted professionals and thank God for it. Members commend them, each and every one, but there are issues here and there are those who clearly are falling down seriously in their responsibility to meet and address issues of what should be shared concern. Under communication and information, the website states, "We listen carefully" while under participation, it states, "We involve people and their families and carers in shared decision making". I have only cited a number of the eight areas, the eighth of which is accountability, where it states, "We welcome your complaints and feedback about care and services". There is no evidence of any welcoming of the feedback on the care and services in these instances.

As for complaints, I do not believe the parents in the circumstances in question were at all met as the HSE states is its policy.

On RTE radio on Sunday, the Minister for Health, Deputy Leo Varadkar, stated parents of babies who died at Portlaoise hospital were "lied to" by people who have been accused of covering up what happened to them. How would Mr. O'Brien respond to the Minister's charge?

For balance, I wish to say I welcomed the circulation last week of Mr. O'Brien's letter of February 2014. I commend him on the action he took and the thrust of the correspondence. It was reported on at the time but I had not seen sight of the construction of the letter. I welcome it very much. Its thrust is absolutely on the button. However, is it not now time to reissue such a communication to all health service staff given that it is evident that a number of staff across the health services are not reaching the high standards Mr. O'Brien himself insisted upon in the communication of 6 February of last year? In light of the evidence of a failure to adhere to the high standards Mr. O'Brien suggests should be the norm across the health services, should such a communication not be accompanied by evidence of enforcement? Are we not now at that point? Will Mr. O'Brien respond accordingly? I fully accept and do not doubt for a moment that the communication reflects Mr. O'Brien's genuine wish for the health services.

There is a significant time lapse before the appointment of an investigation team, reviewer or review panel and this is feeding into a serious lack of confidence. I am speaking quite specifically about maternity services and maternity-related reviews and investigations. The appointment is taking far too much time. Will Mr. O'Brien intervene to insist on these reviews and investigations being conducted not on a part-time basis but on a full-time basis to ensure the earliest possible publication of the findings and recommendations?

With regard to a number of hospitals, specifically Cavan General Hospital, it is a fact 30 months after the tragic death of baby Jamie in November 2012 that we have yet to see a single line published. That is wholly unacceptable to the baby's family and also the wider dependent community. In paying tribute to the overwhelming number of excellent staff who work in the unit in question, I believe it is absolutely unacceptable to them also.

I am ceding time to Senator Crown.

Deputy Jerry Buttimer resumed the Chair.

Deputy Healy has kindly yielded. I am very sorry I was not here for Mr. O'Brien's presentation. This is not a day I normally have blocked off for Seanad activities. I am afraid that there are certain parts of the schedule that have become a little inflexible. I thank Deputy Healy for giving his time to me. If any of my ten minutes are left over, I would like to give them back to him.

The reality is that Mr. O'Brien has been given a certain job and framework within which to work. People who study management systems and health systems would see there is a certain internal logic to the way in which the whole system has reacted. It is not one we would necessarily approve of but there is a certain internal logic to the way certain management responds when certain issues arise.

I will now ask a few brief questions about the response to individuals who had raised issues of concern about the quality of care their families had received and also through their representatives, professionals, the media and public representatives. How much of the response does Mr. O'Brien believe has been formulated directly by those with line responsibility and how much has been formulated by people who are professionals in public relations, stakeholder engagement and the law?

I ask Mr. O'Brien to give a heartfelt answer to another question which is not redolent of judgmentalism. That is because I think certain organisations behave in certain ways because they were set up to behave in these ways. Does Mr. O'Brien think there is a sense that the HSE adopts a reflexly adversarial and defensive posture in the face of quality issues brought to its attention by its clients, by patients? Does he think there is a tendency to suddenly see people who come to raise an issue as somehow being disenfranchised as clients, customers or patients and as something else, as an external threatening force that is now looking at it from the outside?

I suspect that Mr. O'Brien is being put on the grill a little bit, but I want to get his opinion. Does he think we have an abnormal health system? Does he think the health system is, by international standards of comparison, very odd in terms of staffing ratios, the extraordinary internationally unprecedented reliance placed on the efforts of trainee doctors who are still undergoing senior professional and sometimes very junior professional training as actual service providers? In some of the cases about which we have heard in the past few days it is quite obvious that this is the case, that people who were clearly not fully trained and inexperienced were put in the position of having inappropriate levels of responsibility thrust on them.

This is a harder question. We have fought long and hard for systems to deal with disciplinary infractions by doctors, nurses and various other professionals. We have regulatory bodies, some of which the professionals sometimes reckon can act with a degree of heavy handedness. In many cases, they arose in response to prior deficiencies where there had not been sufficiently vigilant regulatory agencies monitoring the activities of professionals. We have them now. The truth is there really should not be any reason a patient, a relative, a bereaved person or anybody who believes the actions of a doctor or a nurse have fallen short of acceptable standards should not have some form of redress involving an appeal to a regulatory body. Does Mr. O'Brien think we have this on the administrative side of the health service because I do not?

The tragic hysterectomy case in Drogheda arose again today. Trust me, I am not doing a collective professional Pontius Pilate in trying to stand up for doctors. There is no doubt that an awful series of fundamentally inexcusable, unforgivable and horrific malpractices which caused terrible life destruction to a lot of people occurred there. I kept looking at it, however, and was thinking about it from the outside saying, what kind of health system lets somebody, operate effectively single-handedly for so long without backup, without a sufficient number of colleagues in place to provide for a degree of peer review, without an intensive care unit, without an adequate number of anaesthesiologists, without the same staff being there on an ongoing basis to see trends emerging, or without a blood bank? In that way, somebody with a severe deficiency and shortage of skills would have been picked out.

It always struck me that there were individuals who had been warned about that system and let it continue. After 22 years the word I use to describe my reaction to try to reform the health service is "despondency". I do not think it is fixable. I was very taken and upset this morning by what I had read in the paper. It was a report that serious, expert, professional notification had been made by senior obstetricians that there were problems. It was not from people who could be dismissed as perhaps inexpert. I would not be the one to accuse them of this, but I am sure it is the kind of charge that is levelled by people who are too emotionally involved. However, serious, dispassionate, sober professionals looked at it and said, "There is a problem here," and it looks like it was ignored.

There has been a great deal of discussion here of the issue of individual versus collective responsibility. We are not supposed to name names, but I will name a few: Howlin, Noonan, Martin-----

I am sorry, Senator, but with respect, I am Chairman of the joint committee.

I acknowledge that.

I will defend-----

Do you deny that these men and women were Minister for Health?

The Senator was late for the meeting and not here for the private session.

Let me make a comment in the interests of balance and fairness. I want to protect all of us in the room and the Senator was missing for the start of the private session. I ask him not to name people who are not here.

I will not. I withdraw the names, but I believe that, collectively, all Ministers for Health in modern times in the State were asleep at the wheel and allowed this to happen. That is the way the system has evolved; they are the people we picked to do it and it is there responsibility rests. It is also from there that reform will come. I am hopeful the new Minister will actually acknowledge, as he seems to have done, that things are really abnormal and need to be fixed. They have needed to be fixed for a very long time.

In the interests of protecting all of us, we had a private session and were given legal advice on naming people. This is not a court of law. As Deputy Billy Kelleher said, the Abbeylara judgment confines us in what we can and cannot do as a committee. I want to protect everybody involved in the hearings today and last week. That is why I am being careful about what members can and cannot do.

I would gladly give the opportunity to all former Ministers for Health to say the problems in the health system had nothing to do with them. I would be delighted to hear them say this.

I have no issue with the Senator naming Members of the Houses, but it is former Members or those who are not here or officials to whom I refer.

Mr. Tony O'Brien

In order that the question about the NPEC does not get lost in my response I will start by asking Professor Greene, the director of the NPEC, to respond. I also remind members that when the Chief Medical Officer was here last week, he made reference to certain actions the Department of Health was taking with the Department of Social Protection on some aspects of how neonatal and perinatal deaths were recorded.

Professor Richard Greene

The question was why we did not have a proper reporting system. Deputy Billy Kelleher asked it. There are a number of things going on and sometimes people get mixed up about exactly what is happening. The majority of our statistics with respect to perinatal mortality, that is, babies who die during pregnancy or in the first week after pregnancy, are provided officially through the birth registration form which goes to the CSO and what was the ESRI but is now incorporated into the hospital pricing office in the HSE. That is where the information comes from. The national perinatal centre was set up to look at perinatal health. It collects data directly from hospitals on a voluntary basis. The information collected is not just on babies but also mothers. The centre is also involved in maternal death inquiries. There are always issues in respect of this kind of information. While I know that it is not kosher today, it absolutely gets to the point to look at maternal deaths. A maternal death inquiry is a confidential evidence-based inquiry which adopts what is considered internationally to be the appropriate approach. It is based on the English system. We pick up about two and a half to three times the number of maternal deaths found in the official statistics. There are reasons for this which we have pointed out in many of the reports in the past few years. In fact, we have started to work with the CSO on that issue in order that we can both ensure we are getting the appropriate numbers.

The centre takes data on babies who, sadly, die. As a practising obstetrician, I note that this is an area that is extraordinarily difficult in terms of management and very pressing and devastating for patients with life-long effects. It also has an effect on us as staff. It is an area that is extraordinarily sad and difficult, but it is also an extraordinary area in which to practise as we can have a great effect in helping people through it.

When a baby dies in a hospital, the report on the event is a completed audit form. It is not just that a baby died but it takes in information about the pregnancy, the mother, time of death and any clinical information on the baby that is available. This allows us to look at perinatal death and the causes.

Every one of these babies and their families are extraordinarily important. It is also important to remember, however, that annually in this country about 450 babies die. Up to 150 of those are associated with congenital anomalies which puts them at a slightly higher risk. The others are associated with many causes, some of which are difficult to detect. One we are now beginning to learn about is that some babies do not grow as well in the womb which accounts for 50% of the normally formed babies who die during pregnancy or around the time of delivery.

We are interested in more than just numbers. We go behind the numbers to find out what happened. One issue associated with one of the reports on Portlaoise was over numbers. There was an issue between the numbers from the CSO, the ESRI and ours. Statistically, it depends on what definition one takes. This country’s perinatal mortality rate for all babies over 500g is just over six per 1,000. That equates to a not insignificant number in total. It is as good as, or better, than most of our European counterparts and internationally significantly better than some very wealthy countries. Norway and other Scandinavian countries are held up as being so much better than us. They quote a figure of about two per 1,000 which makes us look bad. However, if we take the same definition they use, then our rate comes in at 2.1 per 1,000.

We are good at what we do but we still have a significant number of families affected every year by perinatal loss. Sometimes, unfortunately, families and potential parents are not aware of that. I do not believe we will ever completely stop this but we can reduce the numbers. To do that requires investment by us academically and by the health services. That requires society to decide that this is important.

The comparison I drew last week, which may be interesting to the committee, concerned road traffic accidents. There is rarely a day when one turns on the radio that one will not hear about road traffic accidents from the Road Safety Authority, and appropriately so. There are 160 to 180 deaths per year on the roads. Up to 450 babies die. We need to have an understanding of exactly what is going on.

The reporting system we have is adequate. Where it falls down is sometimes around definitions. It could be assisted by having a full-time committed officer to collect and produce this information annually. Like many tasks in our health service, many of us are doing this in addition to our full-time jobs.

Mr. Tony O'Brien

Senator Crown asked some interesting and wide-ranging questions. He asked if I consider that the nature of the health service is odd by international standards.

The objective answer to that question has to be "Yes." The mixed model we have in this country - the blend between public and private - is comparable only to that in post-Saddam Iraq in terms of international comparators. That is one thing that is odd.

The diffuse nature of health service delivery in Ireland, particularly acute care, the number of locations and so on-----

There is a sense of déjà vu in that Mr. O'Brien is hard to hear in the Visitors Gallery.

Mr. Tony O'Brien

My apologies. I will take another drink of water. I will begin again.

In response to Senator Crown's question I was referring to the nature of the health system compared to international standards. There are certain characteristics that are atypical. The particular mix we have between public and private provision is probably comparable to that in post-Saddam Iraq. There are not too many comparators with the same blend. The number of acute locations here is rather large by comparison with that in other developed countries with the same population density and overall population size. The number of smaller units here is, therefore, greater than that in comparators, while our largest units are not as big as they often would be in many locations. There is an over-dependence on agency and locum doctors and doctors in training. We have previously talked about this issue at this committee. There are a number of related factors. Some locations experience particular challenges in that regard because, without wishing to be pejorative, they are regarded by prospective job applicants as geographically peripheral, which simply means that they are not located near large urban centres, large universities and so on, even though they may be near very nice parts of the country. Letterkenny is often used as an example, as is the Midlands Regional Hospital.

Senator John Crown asked a question about the nature of the public response. By and large, the vast majority of instances where it is necessary to issue a public comment on issues related to patient care are handled at local level. Where there are significant issues that have a national focus, by and large, the people in charge of services, either regionally or nationally, handle them. Increasingly, community health care organisation, CHO, and hospital group chiefs shape the nature of the message. They will assess the circumstances and what it is acceptable to say without breaching confidentiality and so on and seek to communicate in a way that is faithful to the circumstance. On occasion, that does mean that it is necessary to have some legal input, particularly if there is likely to be a follow-on process that we do not wish to prejudice. If it is a matter that is likely to become an issue for the State Claims Agency, in other words, a legal claim against the State, we have an obligation to liaise with it. By and large, the HSE is not an organisation that has recourse to external public relations expertise. That would happen very rarely. I suspect we are one of the smallest users of external public relations advice in the State sector. I think that is what the Senator is asking me about in respect of external force.

In respect of disciplinary infractions, there is an important discourse about the nature of regulated versus unregulated professions, not just here but also in other jurisdictions. Administrators or managers are not members of professionally regulated professions, which I think is unfortunate. It devalues these professions and is one of the reasons, at a time when training for managers was eliminated from budgets, continuous professional development funding remained available for the regulated professions because it was a statutory requirement. That meant that people did not receive development training at a personal or professional level to enable them to deal with some of the challenges about which we are talking. It also meant that, as people came into these posts as others vacated them, they were not given access to the professional development training one would have wanted them to have. I believe the contribution administrative personnel make to health service delivery is sufficiently important to deserve that protection and regulation.

That said, the experience of other jurisdictions is that while professional regulation and licensing are important, they can never be substitutes for employer based disciplinary processes. All members of staff in all parts of the health service are subject to the disciplinary code, irrespective of whether they are in a regulated profession. That is as it should be.

In regard to the report in today's The Irish Times, members may not be aware that a small amendment was made to the online version of that article. The document at the centre of the report, which I have read, was a follow-up letter to the Minister of the time sent one day after a meeting had taken place with that Minister. The letter made reference to costed ideas prepared in response to concerns about services in the Coombe, Mullingar and Portlaoise. The meeting was part of an overall service planning process involving clinical programmes in respect of which the HSE applied for €22 million in development funding in 2011. On reading the 2012 service plan, I do not see any provision for that investment, which I interpret as meaning the resources available were not sufficient to enable those programmes to proceed. I was not involved in the service planning process at the time, however. The report in The Irish Times states that I had been involved in that discussion in the capacity of national director of clinical strategy and programmes. That post was held by a different individual, however. The authors of the letter, in expressing to the Minister how they would like to proceed, mentioned a number of people, including me, as people they would like to work with in implementing the proposed measures. It is true that the letter referenced in the newspaper exists, and I have a copy of it.

I have no knowledge of any threats or legal discussions of any kind relating to the "Prime Time" programme. I asked a colleague to investigate whether anybody else had such knowledge but according to the note that I have received nobody on my team has any knowledge. I am aware that members of the HSE participated in the programme, both in the pre-filmed package and in other ways. It comes as news to me that there was any suggestion of an attempt to interfere with the programme, other than the normal process of providing information, asking questions and agreeing who should take part in interviews.

Was there a threat of legal action against "Prime Time"?

Mr. Tony O'Brien

I am absolutely certain that there was no such threat. The only people who would have known about a threat, had it been made, have advised me that they have no knowledge of one. I would expect to have been made aware of a threat.

Was the HSE fully co-operative with the "Prime Time" programme?

Mr. Tony O'Brien

The HSE fully participated. As the Chairman will be aware, in the course of any engagement with the media there is often a discussion about how things should proceed, and there may be a difference of views regarding the level of co-operation. I do not know the details about whether "Prime Time" wanted something that it did not get but it certainly received opportunities to film interviews with the people it requested. I know this from having watched the programme and being aware of some of those interviews taking place.

In regard to HIQA, I received a copy of the first draft of the report with a request that I act in a representative capacity to provide feedback on it. My first question was about what that meant and my second question was on whose behalf I would be responding, in other words, who else had been provided with copies. On reading the report and seeing to whom it might apply, who participated and who, in the ordinary course, I would have expected to be given an opportunity to respond to HIQA as part of its validation process, I became concerned when I discovered that nobody who ever occupied the post of national director of acute hospitals had received even one sentence.

I discovered that the then national director of quality and safety had received one sentence, the then deputy director general of the HSE had received one paragraph, and that no nurse or midwife in Portlaoise had received anything at all.

Does Mr. O'Brien mean they received one sentence or one paragraph pertaining to themselves?

Mr. Tony O'Brien

I mean from the whole report. The draft comprised only approximately 106 pages, given that it did not include the appendices, recommendations or executive summary. In the ordinary course, anybody compiling a report would seek to go back with a draft to people who had been interviewed or who had been involved in matters to which it related. Some individuals received a sentence, three lines or a paragraph, and others received nothing. Based on communications from staff elsewhere in the system, a number of nurses, midwives and other medical personnel had taken part in workshops, interviews and so on, but had received no part of the document to review, despite having requested it. This was my first area of concern.

I ended up writing to various HIQA officials on five occasions seeking some basic information on exactly what was required of me and asking who else had been provided with sections so that I did not need to go through the process. There were issues that did not seem to have an evidence base and for which I asked to see the evidence base. These letters have been published and there is no mystery about them. The central issue was information and a meeting for the purpose of clarifying what was requested of me. If this were a report by any other regulator, such as the Mental Health Commission, an Coimisinéir Teanga or the Comptroller and Auditor General, these matters would not have been considered problematic. Such meetings and additional information would have been provided as part of the normal course.

Given that this particular regulator refused to engage in any way whatsoever, I indicated that I would have to consider seeking intervention, not to prevent the conclusion of the report but to enable me to do what I was being asked to do, namely to make a submission in a representative capacity on behalf of a wide range of people who were not being given the opportunity. I wrote to HIQA to indicate that if I could not get progress, a judicial review would be under consideration. I simultaneously wrote to the Department of Health asking it to intervene, which it did. As a result, we had a meeting at which additional information was provided, the timetable for the provision of a response was agreed, which needed to be extended due to the amount of time that had elapsed, and we made the submission.

Regarding the changes that were made, I am happy to indicate the matters that were not features of the report but which now are. One of these is the recognition that the national maternity strategy which, as per the Chief Medical Officer's report, was to be published by December 2014, was a matter within the determination of the Department of Health rather than the HSE. In the initial draft there was a critical line that said the HSE was at fault for not having published a White Paper. As members will be aware, a body such as the HSE has no role in the publication of a White Paper.

Absent from the report was recognition of the publication of a number of national guidelines by the national clinical effectiveness committee and the HSE's clinical programmes including the Irish maternity early warning score, I-MEWS, Communication (Clinical Handover) in Maternity Services, Sepsis Management, The Management of Second Trimester Miscarriage, Guidelines for the Critically Ill Woman in Obstetrics, Resuscitation for the Pregnant Woman, The Diagnosis and Management of Ectopic Pregnancy, and Bacterial Infections Specific to Pregnancy. Also absent was acknowledgement that all hospital were implementing the national early warning score, NEWS, and I-MEWS and that, on average, between 70% and 90% of staff had received full training on their use. The report now acknowledges that significant progress has been made on the implementation of recommendations from the Chief Medical Officer's report relating to the reporting and management of serious untoward incidents, also known as serious reportable events. These include setting up a serious reportable event governance group chaired by the then HSE director of quality and patient safety; publishing a safety incident management policy, which sets out the HSE's policy for managing safety incidents; publishing a list of serious reportable events and an implementation guidance document; issuing a directive to all providers to require them to notify serous reportable events to the national director responsible for their services; and educating staff and training them in respect of safety incident management.

The authority also confirmed that the HSE actively progressed the implementation of recommendations made in the Ennis and Mallow reports in small hospitals.

The authority recognised that it was not the HSE that determined the services to be supplied by any hospital but that it was a matter of Government policy. That is stated on page 46. The authority also amended some of its findings entirely and others significantly owing to various more minor issues.

Are there outstanding concerns? I have referenced the fact that a reader of the report and the media reached the conclusion based on the report that nobody in seniority had responded to the "Prime Time" programme by going to Portlaoise or taking any step. In my opening statement I covered the fact that the then national director had spent considerable time in and that the regional director of performance integration effectively had taken over the hospital on a direct basis pending the appointment of the various other post holders I mentioned in my statement. It would be reasonable for people to look at us completely sideways and aghast if they believed nobody at national level had intervened, but it is completely untrue.

Deputy Billy Kelleher has made reference to the other suggestion about which I have particular concern in this regard, that is, that the issue of patient quality and safety more generally is not on the agenda at senior levels of the HSE. We provided for them a detailed submission which comprehensively refuted that suggestion. As members will be aware, in 2013, with effect from 27 July, the board of the HSE was abolished and replaced by a directorate. To be a member of the directorate, one must first be a national director of the HSE. It is an unusual and transitional governance arrangement, but the effect is that the directorate is a subset of a wider leadership team. The reserved functions of the directorate are prescribed in legislation. The directorate meets to perform these reserved functions. It also meets collectively as part of the leadership team with all of the other relevant national directors. At the time, the director of quality and safety was not a member of the directorate, while other key people whom one would want for any discussion such as the national director of human resources and so on were not members of the directorate. The directorate chose, therefore, to transact the bulk of its business, that is, its non-reserved business, as a matter of generality as part of the leadership team. The agendas for that team include quality and patient safety and they were supplied to HIQA.

In fairness, I refer to chapter 3, page 5, of HIQA's report. I do not want to take issue with Mr. O'Brien or be alarmist, but he used the word "aghast". I am sure he has met the families.

Mr. Tony O'Brien

Yes, I have met some of them.

One could not but be aghast at the testimony they gave us. As Chairman of the committee, someone who is fair and balanced, as Mr. O'Brien will be aware, what upset me, apart from the stories of the families, was that two organisations of the State - I said this to Mr. O'Brien at last Thursday's meeting - were fighting in public about an issue that was about the parents and their children who had died and their families, in particular. It should not have been in the public domain. Second, why are we worrying about reserved and non-reserved functions when the reality is that patient safety is of paramount importance to all of us? I appreciate that Mr. O'Brien has a job to do, as I do. What jumps out at me in HIQA's report is that it is stated in chapter 3, on page 5, that the safety culture was missing.

Mr. Tony O'Brien

I am responding directly to a question asked of me by Deputy Caoimhghín Ó Caoláin. None of my response is intended, as I said in my opening remarks, to take in any way from the serious failures.

No, I accept that, but in terms of the bigger picture, HIQA and the HSE were involved in a spat, which was unnecessary. It looked bad and the ordinary person at home watching the news at night was horrified by what was going on.

Mr. Tony O'Brien

I agree and it should never have been put in the public domain.

Unfortunately somebody chose to do so. Deputy Caoimhghín Ó Caoláin asked me specifically what changes were made and where my concerns were. It is in that context that I have shared that information.

I will just refer to my notes.

Will Mr. O'Brien deal with the other questions?

That is okay.

Mr. Tony O'Brien

The Deputy asked me if I would reissue the communication and I certainly intend to, but it will be in the context of the Florence Nightingale Foundation initiative around reinvigorating leadership for compassion throughout the system which I referred to in my opening remarks. I have already said there is to be a specific disciplinary investigation into failings of compassion, which brings the accountability balance to that communication. So around it, communication will follow.

The Deputy asked in particular about the length of time investigations can take. He made reference in particular to one in Cavan. I will ask Dr. Crowley to comment on that.

Dr. Philip Crowley

I would like to open up by initially apologising to the families - the families present and the families not present - who suffered harm in Portlaoise hospital. I was personally very distressed and sad at the testimonies they have given in various settings, including here today, not only about the failures in care, but clearly fundamentally about the lack of compassion, the poor response to the adverse situation of the death of a baby and people covering things up, hiding for whatever reason.

I have practised for 30 years as a family doctor. I have worked in Central America, in the NHS and here, always trying to work with patient groups to ensure that their voices are heard and that we are responsive to what people who use our services have to say. I have worked all through that period of time to try to improve services for patients and service users. One can only be deeply upset when care breaks down in this way and particularly care in its fundamental sense - in compassion.

Some of the questions relate to that sense of upset. One question from Deputy Kelleher related to open disclosure. We have developed a policy on open disclosure, as he is probably aware. We have an unprecedented implementation programme around it because we understand from the testimonies of the families here today and from other instances of harm to people that the harm is so compounded by how people react after the event that we know we do not have a culture of open disclosure in our health service.

That is why we carefully developed our policy. I commend it to the committee; it is available on our website. It is a very clear policy. It gives very clear guidance to staff on how to behave, how to respond, how to react immediately. We have run 150 workshops around the country to try to train people in truly adopting this approach, which I recognise represents a culture shift in our health service.

What is the timeframe?

Dr. Philip Crowley

We have been training people over the past six to eight months.

To really change the culture to one of open disclosure, we recognise the need to carry out a phenomenal effort in training people. Two people were involved in that - that is the number of people implementing the policy. We are now training trainers to see if we can drive it home, follow it up and ensure it truly becomes embedded. Any investigation from now on and any assessment of how people are dealt with will be done in the light of whether the open disclosure policy, which is clearly communicated to everybody, was properly followed.

Maybe I should come to the investigations now. The time lapse in investigations is another thing that impedes anybody achieving any sense of answers or closure. Historically our investigations have taken too long. There are a number of reasons for this. One would be the difficulty in accessing experts, particularly in the area of maternity. We have heard of the shortages we have in the maternity services. We have had a significant number of demands to seek expertise to facilitate comprehensive investigations and that has caused delays.

Was that the case in this instance?

Dr. Philip Crowley

That is the case in almost all of the delays. Another issue in regard to the delays - the Deputy raised it - is the availability of trained investigators. What the Deputy proposed was to have full-time investigators. That would be one approach. However, we do not know where an incident will occur and we wish to have people trained across the entire health system. We have trained in the region of 800 people - 400 managers and 400 staff - to understand how to investigate something properly. In 2014, we instituted a new policy that was strongly influenced by my interactions with one of the families present and others. It puts a clear timeline on investigations. They should be completed within four months. This may seem like a long time, but it is a challenging timeline because we must source investigators and experts and ensure that due process is adhered to. This work often delays investigations.

I wish to ask about that. As part of the - I hate using the word "testimony" because we are talking about parents - presentations to us this morning, I counted nearly 33 exchanges or interactions between the HSE and the families. In some cases, there was a 20-week delay without a hearing. That is not down to starting an investigation or being unable to source people. That is a lack of courtesy and engagement on one level.

Dr. Philip Crowley

Yes, that is exactly how that sounds. A lack of courtesy. Investigators might not have been identifiable in the local service, but they should be now, having trained 800 people. I hope that the situation will improve, that others do not have the same experience, that people get answers more quickly and that we implement findings more quickly.

Deputy Kelleher made a suggestion about the suspension of internal investigations where a legal process was under way. It is fair to say that there was a time when some legal practitioners tried to deter local investigations when cases were being taken. We raised this matter with the State Claims Agency, which agreed that it should not be the case. I would hate to think that, at this stage, any internal investigation would be suspended because there was a legal action. We have an agreement that this will not be the case, and it is not the case.

Those are the issues mainly relating to me that have been raised so far.

Mr. Tony O'Brien

I will ask Dr. O'Reilly to comment on some of the cultural changes in Portlaoise.

Dr. Susan O'Reilly

I am the new CEO of a very new hospital group, the Dublin midlands hospital group. I was appointed in November 2014. The HIQA review of the hospital concluded in mid-October 2014, so I arrived after that. Subsequently, I met HIQA to brief it on governance changes in particular. I recruited my small management team. We are a small, focused group. Its members came on board in March and April. We lead the development and integration of clinical networks across seven hospitals, those being, St. James's, Tallaght, the Coombe, the St. Luke's radiation oncology network and the three midlands hospitals of Naas, Portlaoise and Tullamore.

One of my first actions after arriving was to assess the situation based on some of the feedback from a variety of reports, for example, from the HSE and the Chief Medical Officer, and on listening to and learning from Dr. Colm Henry, clinical adviser in the national clinical programme, and five of his national clinical leads for acute services. Dr. Henry may comment on that process in due course.

My first change was to clear up clinical governance within the midlands hospitals, particularly Portlaoise, so that there was no risk whatsoever of any physician being confused about to whom he or she reported. In January, my next act was to appoint a new management structure for Portlaoise and to mimic it across the other midlands hospitals. This change led to having a general management level individual who was the lead for all operations in the hospital, with clinical leads reporting to that person for operations and the professional leads - nursing and clinical director - reporting to my group's individuals in those roles who were their professional practice and strategy advisers.

Operations remain the responsibility of the hospital, with which we have maintained and developed a close working relationship.

While we are dealing with the topic of maternity services, I will be more than happy to address other areas in due course.

In respect of maternity services, even before my appointment, there had been substantial change, some of which was outlined by Mr. O'Brien. The appointments of a general manager and a director of midwifery have been enormously successful in beginning the process of changing the culture within the hospital. Cultural change takes time to develop. Staff must feel supported. A balance must be struck between identifying staff who are significantly and consistently under-performing and who should, perhaps, undergo a fitness to practise or disciplinary process and those staff who may have made a clinical judgment call that in retrospect was not right.

The families who presented to the committee have suffered terrible losses and rightly complained about how they were treated. Often, clinical staff, in particular nursing, midwifery and allied health staff, are afraid to be open because they are afraid of the shame and the blame. It is our job to balance ensuring appropriate discipline for under-performance with appropriate support and open disclosure. These two elements can sometimes counter-balance each other and it takes a while for that culture to evolve. The new director of midwifery, the new clinical lead appointed last year prior to my appointment and the new manager began that change. We are investing in quality and safety complaints management and elements of patient engagement. To date, 16 additional permanent midwifery staff have been appointed, bringing total staff numbers to 72. Another obstetrician has also been recruited, bringing the total number of obstetric staff to four. More particularly, the memorandum of understanding with the board of the Coombe hospital, the infant and maternity hospital, was signed by me and the board chairperson in March. The process of the Coombe hospital taking over the governance and management of a Coombe hospital on two sites, in Portlaoise and the Coombe, is under way.

A director of clinical integration from the Coombe hospital went on-site over one month ago. The role of the director of clinical integration who is a senior obstetrician is to integrate and standardise clinical pathways and policies across the groups. In the interim, there has been progressive and completed work on ensuring appropriate training for midwives in CTG, cardiac monitoring for the foetus-baby during pregnancy and delivery. There has been consistent development and implementation of policies for the safe use of the drug oxytocin and considerable investment in the restructuring of maternity services in that there are now shift leads to whom midwives delivering babies can go, as well as the medical staff. We also have a bereavement support midwife, breast-feeding support, midwifery education support and a number of other structural changes that give confidence to midwives who are in the field delivering babies and working with the medical staff that they have a structure to support them in their education, development and training.

There have been substantial improvements to date at Portlaoise hospital. Although born out of tragedy in terms of the Chief Medical Officer's report and the "Prime Time" programme, we have landed in a good place. We must thank the families for their pursuit of and engagement with excellence. We are achieving consistent and safe services today which will continue to get better as we move towards the new networked model of the Coombe hospital on two sites.

Mr. Tony O'Brien

I must apologise to Deputies Billy Kelleher and Caoimhghín Ó Caoláin and the Chairman in that the answer to the question of whether patient safety was on the agenda was in response to Deputy Billy Kelleher's question. I was slightly confused; my apologies.

On the matter raised this morning with the committee by, I think, Mr. and Mrs Molloy and about officials saying, "We are only here to listen," the transcript of this morning's meeting will be examined in the context of the investigative process to which I referred.

They were also told, "You have had your say; now it is my turn."

Mr. Tony O'Brien

Yes. I have had that reported to me as being one of the things that was said this morning.

As I said, that will be in the transcript and be part of the investigation process.

There is the question of the Minister's term of "lied". I watched some part of another "Prime Time" programme in which there was not open disclosure or candour, so the truth was not told. I would not call it a lie at this stage but I understand why that term would be associated with it.

It comes to the same thing for most of us.

Mr. Tony O'Brien

It does but in the nature of a disciplinary process, I must be just a little more careful. I believe the issue of open disclosure would be better placed in a legal construct. I personally am in favour of a legal duty of candour. That would be in everybody's interests. The open disclosure policy we have pursued does not currently have a legal framework underpinning it and it is mandated within the organisation. It is being used very extensively but it was not in place at the time.

There is the issue of the implementation of previous reports. There is acknowledgement that the recommendations of the Ennis and Mallow reports have been implemented. Clearly, they were not fully implemented in Portlaoise as to do so would have conflicted with a policy position of the Government. The nature of the reconfiguration of the remainder of the small hospitals, as per the small hospitals framework, has occurred. It would not be appropriate to suggest that there has not been implementation of those previous reports. With regard to the O'Malley report, I played a key role in the implementation of the national cancer strategy, which had the effect of implementing many of the recommendations in the report. Dr. O'Reilly has played a continuing role in that regard. There has been very significant implementation - completed and ongoing - with respect to the HIQA inquiry that I asked for with regard to the death of the late Savita Halappanavar. There has been significant implementation that is ongoing with regard to the recommendations of the chief medical officer. There are some generalised comments about failure to implement but when one considers the detail of those recommendations, there is very substantial implementation. There was a combined oversight group with the small hospitals framework that included HSE, Department of Health and HIQA representation.

With regard to the implementation of further recommendations, the model that occurred with respect to the small hospitals framework - the so-called Ennis and Mallow framework - is good. One of the recommendations of HIQA is that the Minister would put in place an oversight mechanism to monitor implementation. That mirrors what happened on that occasion. The Minister has committed to doing that and it is appropriate. Where HIQA has indicated it is for the HSE to implement recommendations, it is because the HSE needs to implement them. The HSE is the only body that could implement them, it will do so and it will be supported in doing so by the oversight mechanism the Minister has referred to.

The State Claims Agency issue is a reference to a section of the report. It is a reference to a review in Portlaoise referring to meetings that took place approximately eight years ago between State Claims Agency representatives and managers from what was then called the midlands hospital group. The first meeting, which took place in November 2007, discussed the potential order of maternity services at Portlaoise hospital. That meeting considered the need to conduct the proposed audit in view of the fact that the hospital had identified and accepted the problems that were of concern to the State Claims Agency, had an action plan in place to address them and was conducting a related incident investigation. A further meeting was arranged in December 2007, at which it was agreed that in light of the information provided by the hospital and the HSE after the November meeting, a review of the maternity service in Portlaoise was not required at that point in time. That is a position that has been discussed and it is an agreed position, as it were, in terms of what happened at the time between the HSE and the State Claims Agency.

The truth is the HSE has an extremely good working relationship with the State Claims Agency.

Personnel across the health service have multiple interactions with the agency at various levels and on an almost daily basis. This relationship is a critical component of risk and incident management across the health service. Since the time referred to in the HIQA report, the State Claims Agency has also augmented its own approach and makes earlier and more direct contact at senior levels both within hospitals and-or with HSE management where this is required. This process is fully supported by the HSE and involves formal interactions at a national level between the two agencies.

Would you say that the HSE has due regard for the State Claims Agency's patient safety data?

Mr. Tony O'Brien

Yes, although a new system called the national incident management system or NIMS has been rolling out since January of this year. This involves a process that will give the corporate divisions of the HSE direct access in real time to that data. Currently what happens is that the State Claims Agency runs reports on request. In future - and this will be sorted out as part of the planned process for the implementation of this system - at corporate level there will be direct access to that data which there is not at present. There has been an historical issue about access to data in voluntary hospitals and that is being resolved at present. That will provide a much more cohesive system. NIMS, when fully deployed, will enable the HSE to roll in aspects of our own quality and patient safety tracking systems so that there is a single system and the coding to enable the serious reportable events to be captured on that system is currently being put in place. It will then be a singular system.

Dr. Susan O'Reilly

Portlaoise is fully implemented in that.

Mr. Tony O'Brien

Portlaoise is fully implemented in that regard already.

On the issue of inquests, obviously where there is to be in inquest, that is a matter of statute and the inquest must proceed. As Dr. Crowley has said, in the past - and I do mean the past - there was a culture whereby the point at which a medical negligence or other claim against the HSE or the State was initiated had an impact on relationships and the ordinary process of engagement. This came into particularly sharp focus in the context of persons suffering from narcolepsy who may have that condition as a result of a vaccination process, where there was a suggestion that certain supports would be provided only to persons who were not engaged in legal action. I intervened at that time to make it absolutely clear that the relationship between the HSE and its patients or clients must not in any way be affected by whether individuals had or had not initiated legal action. In the past, as Dr. Crowley has said, that was an event that occasionally interrupted the normal process but that is no longer the case and should never have been the case.

On the use of freedom of information requests, the Freedom of Information Act should never be something that patients have to rely on. I am familiar with the fact that Mark and Róisín Molloy had issues in that regard. When I met them with Ian Carter last year, we ensured that they received every piece of documentation that was connected with them. The method we used was that anything that had their name on it or the name of their late son, Mark, was provided to them at that point. It should have been provided sooner. It is absolutely clear that patients are entitled to their information, to information relating to them or to information relating, in this case, to their late children. That is very clear.

I hope that I have not overlooked any of the questions posed.

We will bring Mr. O'Brien back in again if there are any outstanding questions. Seven members have indicated their desire to speak so I would ask them all to be brief. Deputy Regina Doherty is next.

First of all I would like to say that I wish Dr. O'Reilly the very best of luck. There has been a considerable loss of trust in the services being provided at Portlaoise and she has her work cut out for her. That said, I genuinely wish her the very best.

Mr. O'Brien came in here this afternoon and in his first correspondence with us he spoke about costs and resources as an issue with regard to the provision of services. I am curious as to why, given that we all defended the HSE service plan for 2014 in which patient safety was mentioned in the opening paragraphs somewhere between five and ten times.

Given our concern for patient safety, when it was discovered the Midland Regional Hospital, Portlaoise was 16 midwives shy of the number required for a hospital with a 24/7 accident and emergency unit and that the one consultant was only working four days a week, why did top management of the hospital or the HSE not react by either closing down the services or at that point decide to resource them? Why did it take the "Prime Time" programme on the awful tragedy the Molloy family experienced in the hospital before Ian Carter went to Portlaoise?

With respect, when Mr. O'Brien talks about the HIQA report being a watershed with changes being made now, did the 86 families whom the Minister for Health met last night, who in the past number of years had told their stories and testimonies to the senior management in both the hospital and the HSE up to office of the director general not of itself sound an alarm bell to signal that something was wrong with the delivery of services? Did top management not realise they would need to go to Portlaoise and address the issues arising from the services? Did the top management need to wait for a "Prime Time" programme or a HIQA report to deal with the problem?

When Dr. Philip Crowley wrote to me, his title was national director of quality and patient safety, but today he is listed as the national director of quality improvement. Is that not ironic? If Dr. Crowley is no longer in charge of patient safety, who is responsible for this role? During the time he was in charge of patient safety, which was until at least February of this year, how many times did he go to the Midland general hospital to discuss the adverse incidents that had happened in the hospital and the actions that would need to be taken? The report of the inquests made recommendations on the changes that needed to be implemented. How many times did Dr. Crowley discuss with the local management how the changes should be costed, resourced and implemented?

I have major concerns about the quality patient safety directorate, but as I do not want to bring the committee into disrepute, let me state that personally, I have no trust or confidence in Dr. Crowley's ability to manage the patient safety authority. The facts speak for themselves. We have had so many adverse incidents during his period in charge, and not just in maternity service, that if I were in that role I would be questioning how we are actively looking at patient safety.

I thank the witnesses from the HSE for their presentations. I wish to touch on the perinatal mortality rate, an issue that was raised this morning. I tabled a commencement matter in the Seanad on 14 May on the need for the Minister for Health and the HSE to publish the 2014 perinatal mortality rates for each of the 19 maternity hospitals in view of the recent adverse media coverage on this matter. The Minister replied to me on 14 May, but I have not got the figures for each individual hospital. He stated:

The notification of still births is a mandatory requirement in the Civil Registration Act 2004. This Act was amended in 2014 to make notification of early neonatal death mandatory. The general registration office is working on the commencement of this.

Who is obliged to do the reporting? I am a little confused about the registrations. Is it the hospital or the parents who are obliged to report the death? In his letter of 14 May, the Minister further states: "The general registration office is working on the commencement of this". When is it likely to be commenced so that we have a proper system in place?

Another issue raised in the letter was about clear definitions. I know Professor Greene raised the number of different ways of approaching the issue. Can we have a clear definition at this stage? Are the figures for 2013 available? When is it likely that we will have the figures for 2014 in respect of each of the 19 units?

A report was produced in 2006 about the need for further midwives in Portlaoise. In the body of the report the Institute of Obstetricians and Gynaecologist recommended that the Coombe Women's Hospital and the Midland Regional Hospital, Portlaoise would work together, yet it took a number of years before that happened. As we have touched on the recommendations in respect of the hospitals in Galway, Ballinasloe, Portlaoise, Cavan, are there recommendations that were made six, seven or eight years ago in respect of other units around the country, that have not been implemented? When are they likely to be implemented? It is important that we do not wait for another tragedy to arise before these recommendations are implemented.

I ask the witnesses to deal with that in the context of other maternity units.

On page 92 of the report on Portlaoise reference is made to access to theatre. Is a solution being proposed for that problem? I understand that access to theatre is also an issue in a number of other maternity units which are sharing theatre space with the general hospital. Have those units been identified and what programme of action is proposed to resolve this difficulty? How many units do not have dedicated theatre space and for how many units will this problem be resolved? When is it proposed to deal with the theatre issue in Portlaoise specifically?

Deputy Mitchell O'Connor is next.

This morning we heard harrowing reports from the parents of Mary Kate and Mark. They were upset, staff were upset and so were members. I thank Dr. Crowley for apologising. Has Mr. O'Brien apologised to the parents for what has happened? I may have missed it. Dr. O'Reilly has reported that things are improving and new systems have been set up. Can I have a watertight guarantee that what happened to baby Mark's parents, in terms of them e-mailing back and forth, trying to get information, will never happen to another parent who loses a child in a maternity unit? I was very concerned when I heard baby Mark's parents state that he was registered as stillborn. Is this normal practice in a hospital when a baby lives for a short time after birth to register that as a stillbirth?

I asked the parents numerous questions and thought they were very generous in their answers. I commented to the effect that we all know that human error can occur in a hospital. While they agreed and said that they understand that human errors happen, they argued strongly that failures must be investigated fully in order to be prevented in the future. I want to know, as do the parents, if a formal or informal decision was made by senior HSE staff or senior management in Portlaoise not to act on the human errors that occurred that day. As the parents said, nobody went into work that morning to cause harm. They also said that there are departments of audit, risk management, advocacy and complaints in the HSE. Are all of those departments still in existence and if so, could the witnesses tell us what they do?

I wish to ask the witnesses about the lack of a safety culture in the hospital in Portlaoise, as referred to in the executive summary of the HIQA report. Page 9 of that report reads as follows: "It is also evident that at this time, the hospital's senior management team did not collectively conduct formal safety walk-rounds". Is that happening now and is it happening in the other maternity units across the country? I find it incredible that this is not happening in our hospitals. Were the senior management and the people responsible suspended, reprimanded, put on paid leave? What happened to them?

The parents also mentioned the qualifications of staff that day and the fact that there was no-one available to carry out a CTG test. Had that been done, the baby could have lived. The witnesses have told us that staff are being trained in cardiac monitoring.

Is that the case in other hospitals? Can a mother who is to go into hospital this evening tonight or tomorrow to deliver a baby expect the staff to have been trained in cardiac monitoring?

I ask the committee to break with precedent and allow Deputy Creighton, who has another appointment to go to, to come in next.

I thank the Chairman and members. I do not often beg indulgence but I appreciate it. I am anxious to ask one or two questions of Mr. O'Brien. We were told today by the parents of two babies who died in Portlaoise that the HSE management is clearly incapable and cannot be trusted. They told us that information was deliberately suppressed, as were known red flags. The story goes on and on and it is apparent from the contents of the HIQA report and the evidence this morning that there are huge failings at all levels - national, regional and local. Ms Amy Delahunt also told us this morning that the director general of the HSE must stop misinforming the public that these events were before his time with the HSE.

A number of instances of correspondence were drawn to our attention, which I want to raise directly with Mr. O'Brien. First is a letter of 26 October 2012 in which Mr. O'Brien wrote to Mr. and Mrs. Molloy saying, "I am disappointed to learn from your letter that you were unable to get an adequate response previously but I can assure you that Dr. Philip Crowley will actively deal with this matter." On 25 November 2012 the Molloy family, Mark and Róisín, wrote to you in your capacity as director general of the HSE, the head of the organisation. They said, "We cannot begin to put into words just how frustrated, appalled, angered and upset we are". In a lengthy piece of correspondence, they went on to say:

We are not the only family whose baby has died in worrisome circumstances in the hospital in recent years, yet there seems to be a blatant ignoring of this hospital's obligations in relation to having these deaths investigated. What is even more concerning is to learn that, despite these deaths and birth injuries to other children, this hospital has never been audited.

The Molloy family implored you, they appealed to you, as director general of the HSE to act to ensure that no other family would suffer the way they had at the hands of the HSE. Thanks to their assiduous work and through their resourcefulness we have also been made aware that a meeting took place on 6 December 2012 between Mr. O'Brien and Dr. Philip Crowley at which there were two agenda items.

I ask the Deputy to finish and I remind her not to name names.

The first item on the agenda was baby Mark Molloy and the reporting relationship. No minutes of the meeting are available but it is documented and it did occur. How can Mr. O'Brien say that he is not responsible, that he was not there and that he had nothing to do with it? We know that other deaths occurred in 2013 after these appeals by the Molloys to Mr. O'Brien as director general of the HSE. How can Mr. O'Brien say that he is not responsible and how can he not feel in any way accountable for these occurrences? I cannot comprehend how he can suggest he is not responsible given that he was directly written to on a number of occasions and he attended meetings where this issue was addressed and nothing happened.

The next speakers will be Deputy Healy, Senator Gilroy and Deputy Catherine Byrne.

I am due in the Chamber to speak on Private Members' business shortly so I thank the Chairman.

The HIQA report confirms, in all material respects, the experiences the families had at hospital level, at local level, at regional level and at national level.

I understand the HSE, including Mr. O'Brien, had concerns over the draft report. The report is out now. Does Mr. O'Brien accept the HIQA report, as published? Will he commit here to implementing its recommendations? Can he give us a timescale for the implementation of the recommendations of the report in so far as it refers to the HSE?

As we all know, the report is shocking and damning. One of the points that is most difficult to understand is the lack of humanity and compassion for the families during this whole nightmare. Can Mr. O'Brien give any explanation to this committee and the families as to why the latter were treated with such a lack of humanity and compassion?

The report shows failures at all levels of the HSE. It shows a dysfunctional system with systemic failure and what would appear to be a culture of inaction. Does Mr. O'Brien accept that there have been failures at all levels, locally, regionally and nationally, in regard to this matter?

Let me outline a matter the families are particularly annoyed about. They believe, and have said here this morning, that the HSE was involved in a cover-up and that they were encouraged to sue in the hope their doing so would deflect investigations. One family - Ollie and Amy - told us they were told by the staff at the hospital that they were the only family that experienced this particular difficulty. Of course, they heard since that numerous families were told the very same thing. One wonders whether this was a policy of the hospital and the HSE. There was certainly misinformation, and it must have been deliberate misinformation. Can Mr. O'Brien indicate how this could have arisen and how the family could have been given misinformation deliberately?

The question of staffing was also raised. It was raised in 2006 and again in 2008 but not acted upon. Despite this, it was possible to act on it when these difficulties arose. Families would like to know why, when these difficulties concerning staffing arose, they were not dealt with at the time.

Does Mr. O'Brien believe the HSE is fit for purpose? Is it capable of running the health service? Does Mr. O'Brien accept that only an independent inquiry into this matter would be capable of bringing an end to the nightmare experienced by the families?

Mr. O'Brien started his contribution today by acknowledging the convention that contributions are circulated in advance, but he deviated from the convention. Why did he not circulate his response to us?

There is no obligation on any witness appearing at any committee, be it a Minister or a witness we have invited, to provide a written script or to have one.

I understand that but I was just curious about it. That leads me to my second point. At this morning's session we heard powerful and moving contributions from the families. The one message that I heard very clearly concerned the difficulty in obtaining information. I am very frustrated by what I am hearing this afternoon because in my view, Mr. O'Brien's contribution bears very little relation to the HIQA report. His response was defensive, reflexive and legalistic, with more regard to process than to explaining. That is what I am looking for today but I am no closer to getting an explanation now than I was before the meeting started.

We have heard about the legalistic and regulatory obligations, disciplinary procedures, oversight, implementation programmes, cultural shifts and so forth. We even heard terms like "subset of a directorate". The submission was laden with jargon and seemed to be designed to obscure the issues rather than to enlighten us. I am sorry for being so harsh but this is how I feel about it. Mr. O'Brien seemed to be suggesting that one of his concerns about the HIQA report was the absence of reference to individuals.

Mr. Tony O'Brien

Could the Senator repeat that please?

Mr. O'Brien seemed to be suggesting in his contribution that his concerns relating to the HIQA report were primarily due to the absence of reference to individuals. I ask him to elaborate on that point.

Mr. Tony O'Brien

I did not say that.

He did say that. Finally, when there was talk about legal obligations and judicial reviews, did Mr. O'Brien have any regard to how the families might have felt on hearing such public pronouncements at a time when one of the most emotive topics was being discussed widely in the media?

My final point relates to cutting budgets in the areas of training and advocacy. I would have thought that during times of constrained budgets, these are the very areas where budgets should be maintained, if not expanded, in order to maintain quality of service. I ask the witnesses to comment. I am sure they can hear the sense of frustration in my voice but I feel that I am no wiser now than I was before they spoke.

Deputy Byrne is next. We left the best wine to the end.

The Chairman should not say that. He is raising expectations. What happened in Portlaoise hospital is a reflection of very bad management. Mr. O'Brien referred to compassion seven times in his opening statement. He spoke about not doing unto others anything that one would not like done to oneself. However, for the families that were here this morning, there was no compassion. One woman reflected on the lack of compassion she had experienced following the loss of her baby, recounting that a small, simple act of humanity would have provided much needed comfort during that moment. When one has to bury a loved one, it should be all about compassion and humanity in a hospital. If that is not there, then the whole basis of the health service is lost completely.

Page 8 of the executive summary and page 21 of the main HIQA report reads as follows: "However, it is apparent that despite overwhelming evidence to indicate that the local management team at Portlaoise Hospital was struggling to deliver the service, there is no evidence to show that regional HSE managers took effective control of the situation at that time." That is the key issue. Why did nobody call in the fire brigade when it was known that there was a problem? The situation could have been approached in a totally different way.

I was very happy to hear Dr. O'Reilly speak about the link between the Coombe and Portlaoise hospitals. Has that happened yet?

I am listening, but I am hearing different accounts of it. If it has not happened, why has it not happened? When will it happen? Something needs to happen in the Midland Regional Hospital, Portlaoise. As Dr. O'Reilly said, steps have been taken to ensure that a proper service is being provided.

I read this report right through. It was the most chilling report I have ever read. Some parts of the report were a nightmare to read. Mr. Ollie Kelly finished his contribution this morning by saying it was unforgivable what happened to his beautiful Mary Kate.

If anything is to come out of this meeting for the families who are here, it is the need to put in place a healing process for them and everybody else who was affected by what happened in this hospital. If that does not happen, I do not think the HSE will ever manage the hospitals it runs. There is healing when people sit down and listen to each other but there must be compassion and humility. I am speaking from recent experience of burying a family member. When we were around the bed of the person last week, it was all about compassion and humility. If we cannot have that in a hospital situation, we might as well forget about it.

Mr. Tony O'Brien

I was asked why I did not provided a written statement. The reason is that essentially I found it almost impossible to write one. Each of my statements I make are written by myself, but when we have our quarterly meeting, there is much input from many colleagues. When I sat down to write a statement for today's meeting, I was able to identify the areas I wanted to talk about, but not to write it. I wanted to appear before the committee and speak on the issues without reading from a script as I would have felt uncomfortable reading from a script in the circumstances. It is not the case that I had a script but did not provide it to the committee. I did not have one. I gave the committee the headings. For myself, I had written down the key words to remind myself of things that I thought were important to mention.

I regret that Senator Gilroy does not feel in any way enlightened, that is unfortunate and suggests we failed somewhat in our task today. We will reflect on that. He asked whether I had considered how families might feel in the context of the discussion I have had with HIQA. It never entered my radar to expect that within 24 hours of having had the meeting with HIQA, having agreed a way forward, being provided with additional information and having been given a timeline within which we could respond, that it would find its way into the public domain and be presented in the way that it was. I had no expectation that would occur. I think it is reasonable that I would not expect that to occur. I would expect to be able to engage in discourse with any regulator and for that process not to result in the type of thing that went on. Inevitably that has caused all sorts of concern among those who are at the centre of this investigation. It was suggested that we were attempting to ensure that there would be no report. That was never the case. All I wanted to do was to be facilitated to deal with what was asked of me, which was to make a submission that would be part of the normal process.

There are things in the report that would not be there if the submission had not been possible. I have already outlined some areas in the report where I think there is room for further improvement. We have already covered that ground. I agree with members that it would have been better in the years from 2008 to 2012, inclusive, if training budgets had not been cut. When I became effectively the acting chief executive officer after being designated as the future director general, my first action was to begin to restore training budgets. What we experienced in those years was unavoidable.

The situation the country faced meant that emergency measures had to be taken. There is no question about that. However, they had quite a corrosive effect on the relationship between managers and staff at all levels in the service. A significant amount of talented managers and leaders left the organisation. Others had to assume their roles without the benefit of enhanced training to facilitate them.

One of the things I reflected to HIQA and previously in this committee is spelled out in the service plan for 2014. All that focus in public discourse on budget overruns, deficits, staff head counts and too many administrators - all those headlines we have all seen - drove many levels of the HSE and the organisations it worked with to become excessively concerned about those issues, often to the detriment of being able to spend time focusing more on other issues such as access, quality and safety. The committee will find a reference to comments I made in the report that are also reinforced by HIQA's reading of correspondence I had with the Department where I said back in 2013 that we needed to renew the focus completely on quality and patient safety. I cannot tell the committee the page number. I think it is in the final chapter. I made that reference to the investigation team as part of seeking to secure its understanding of what I was about, that five years of that does not get turned around terribly quickly and that I am in the process of doing that. I wanted the team to understand by giving it the letters of determination and the head count reduction targets, none of which has ever been met while I have been director general because I have not really prioritised the head count reductions. I do not think they are sensible. They often increase costs and reduce safety. I have always told everyone that across the four factors performance is measured by, one of which is the use of human resources, achieving arbitrary head counts is the least important. As the Chairman is aware, I have often got myself into some trouble for the stance I have taken on some of those things.

In response to Deputy Regina Doherty-----

Notwithstanding the remarks made by Mr. O'Brien and the issue of resources and training, some of the things that happened to the parents and families involved obfuscation, procrastination, delays in answering questions and a lack of courtesy. I once worked as a hospital porter in Cork University Hospital. We were told three things: to respect the patient, treat patients as human beings and always remember where we were from. That was not done in this case. One can have all the money in the world, and I accept what Mr. O'Brien is saying, but the way the families were treated in some cases was beyond human decency. It was lacking in human decency.

Mr. Tony O'Brien

I accept absolutely what the Chairman is saying, but if we are to have a really grown-up discussion, which the people in the room want, we must discuss both of those things. My first remarks were about compassion. I did not realise I said it seven times. Deputy Catherine Byrne reminded me of that. No one here is seeking to explain or excuse any of that but that does not mean we should not also talk about some of the resource issues that have affected the Midland Regional Hospital in Portlaoise or other hospitals. It would be unfortunate if we got into a situation where because there was an inexplicable and inexcusable breakdown in care and compassion or compassion in care, this is the only discussion we need to have because it is not. Any reports on this situation in the context of where the health service has been and where it needs to go that do not address the fact that we have only half the obstetricians in this country that we need is missing half the point. While in some respects I would be on much safer territory coming in here and just saying that we should only talk about why people behave badly, I would be in dereliction of my duty if I did that. I want to be open and honest with the committee about that.

There were specific questions about theatres and other issues in the Midland Regional Hospital in Portlaoise and other places. I will ask Dr. O'Reilly to talk about the situation at Portlaoise and I ask Mr. Woods to talk about the national situation.

Dr. Susan O'Reilly

There was a question about access to theatres, relating to page 93 of the HIQA report. The issue here was less about access to theatres than access to a surgical team if there were two consecutive urgent or emergency caesarean sections. There are two theatres in Portlaoise. The bulk of the work in the theatres is obstetrical and the issue that arose is what would happen out of hours, at night or on the weekend, if two mothers required an urgent caesarean section. This only occurs perhaps twice or three times a year, because the theatre space is there. Last autumn, Portlaoise put in place a back-up clinical team, so it can have the additional doctors and midwifery staff on call and two simultaneous caesarean sections can be carried out should the occasion arise. That issue has been addressed.

Moving to the broader questions about guarantees regarding the disrespectful or lack of compassionate behaviour towards the mothers or parents involved where a baby has been lost through a stillbirth or a neonatal death, I can give the committee my absolute commitment for the two maternity services within our group, comprising Portlaoise hospital and the Coombe, that engagement with the family will happen immediately. It must. In my clinical practice, and I am a medical oncologist cancer specialist, and also in cancer leadership in Canada and in this country, I learned the lesson many years ago that one is only making the families or the patient increasingly miserable, angry and hurt if one does not engage immediately. One is doing no favours if staff back-off from the situation, perhaps out of their own anxieties or distress. That engagement must be there and it must be compassionate. One must have bereavement support for patients and psychological support where needed. It absolutely must be provided. I make my personal commitment on that.

One can never guarantee that babies' lives will not be lost. The committee has heard Professor Greene talk about the small numbers of babies that are documented as dying around childbirth, but the issue is how one deals with it. It is absolutely critical that we adopt and implement fully the open disclosure and also the patient support. It is still an excruciating experience, but the one message I have heard most frequently from all of the parents involved is that they do not want their child's death to be in vain and that they want to see change. I believe change is happening and will continue to happen.

In general terms, I cannot comment on the history of what took place in individual situations in 2012 and 2013. I was heading the cancer control programme then and I only got engaged in the hospital group leadership in November 2014. I cannot say anything relevant to that because I do not have that historical data. Perhaps Dr. Crowley and Mr. O'Brien could comment if necessary.

Again, I will not address the HSE approach to audit, advocacy, risk and complaints. However, as I already mentioned, we have a very effective complaints process and complaints officer in Portlaoise now. Complaints are almost all resolved within the 30 days required. An advocacy programme is beginning and we have a very highly skilled individual on site who will begin her work at Portlaoise but will roll it out for the other hospital groups as well under Liam Woods's leadership. We are doing clinical audit. We are not auditing absolutely everything, but we are auditing that we have the full engagement of the maternity staff in using all of the early warning requirements to monitor patient progress. That is carefully audited. The risk management processes have up-scaled substantially. Risks are being managed, documented, reviewed and recorded.

As an aside, I have taken over commissioning some of the investigations that were already ongoing. I agree that some of them have taken too long. I also agree that part of the issue is that it is not easy to have obstetricians or other clinicians volunteer their time to do this work on top of their day job. They also require indemnification from their professional bodies and a number of other structures to be put in place. However, I can certainly commit regarding any of the reviews I have taken into my office that if anybody gets in touch with my office we engage right away and if reports are to go out we are endeavouring to get to the end of the road. There are still some legacy delays that I am endeavouring to manage at present and some communications, but that is ongoing. That includes some of the work being done by Dr. Peter Boylan and his team in respect of maternity complaints.

Walk-arounds are happening. The culture of safety is embedded in the maternity services at Portlaoise hospital and also is in progress in the general hospital services. In regard to the operation of continuous cardiotocographic machines, CTGs, all midwives receive the required training as part of their electronic module. Each new member of staff is signed up to attend a workshop, with workshops being held approximately every two months. Staff are mandated to undertake the electronic training and, in addition, shift supervisors and the director of midwifery will supervise, engage and continue to instruct. Learning does not just involve a single e-module or workshop; it is a continuous, lifelong clinical improvement project. It is important to state we now have people well trained at the midwifery and junior hospital doctor level and that we intend to sustain this. In addition, we have staff trained in ultrasound technology to a higher degree than was previously the case.

I hope I have covered all of the questions addressed to me by members.

Mr. Liam Woods

Regarding access to emergency theatres, there is that access in the stand-alone maternity units and general hospitals. There have been changes in Cavan recently, for example, to ensure the theatre roster allows for this.

Mr. Tony O'Brien

My colleague, Professor Greene, might respond to the question about reporting and the classification of stillbirths and neonatal deaths.

Professor Richard Greene

This is probably a somewhat dry subject for many people, particularly those who have lost babies, but I will endeavour to clarify the point raised by Deputy Mary Mitchell O'Connor. The legislation refers to a stillbirth as involving a baby without signs of life at the time of birth, while a neonatal death is considered to occur if the baby dies after birth and has shown signs of life. However, there is no definition or description of what is encompassed in "signs of life". Essentially, if there is a heartbeat or gasp, it is taken as the baby having shown signs of life.

To clarify, if a baby dies after, say, one minute, it is classified as a neonatal death?

Professor Richard Greene

Yes. A baby might have a heartbeat that is gone in one minute or give a gasp and show no further sign of life. Where any such sign of life presents, it is considered to be a neonatal death.

There were several questions about reporting and registration. Registration of stillbirths is required where the woman is at more than 24 weeks gestation or the baby weighs more than 500g. Reporting in this regard comes either from the likes of the ESRI or in the audit-type work we do. There is also a requirement for certification of death, which occurs at some subsequent point. The requirement is that the doctor complete the death certificate for the baby, but it then may be given to the parents to submit to the General Register Office. The report on Portlaoise hospital suggested we review this procedure. Dr. Crowley and I met the chief medical officer, CMO, and subsequently the healthcare pricing office, HPO, to discuss the issue. As a consequence of these discussions, we have agreed to follow in the future the World Health Organization definition, which is that baby deaths will be documented in the statistics if the baby weighs more than 500g.

A question was asked about the publication of reports for 2013. The perinatal statistics for that year were published in December 2014 by the HPO. The 2013 clinical audit of the data we receive will be available later this year. It requires a lot of clinical information and there is sometimes a delay in the data for final cause of death arising from referrals to the Coroner Service.

Mr. Tony O'Brien

There was a question asked about the escalation of staffing issues in Portlaoise and Ms McGuinness can speak to that.

Ms Laverne McGuinness

The member asked why 16 nursing staff had only now gone in and if this had not been addressed beforehand. Staffing in Portlaoise was addressed on a number of occasions. As members are aware, a moratorium was introduced in 2009, under which nursing staff could not be replaced. However, in October 2010 Portlaoise hospital was short particularly in its midwife staff and staff in the special care baby unit. In October 2010 five additional midwives were sanctioned for nursing staff at the special care baby unit. They went in between February and March 2011 because it takes a period of time to recruit.

Again at the time, members will recall the grace period when there was a large exit from the public sector based on troika agreements. That was supposed to be based on a non-replacement policy in order to deliver the amount of money that was required for Government at the time, but we carried out a risk assessment particularly regarding maternity services at Portlaoise. At that time we asked the hospital to carry out a risk assessment with its clinical director, nursing director and regional director of operations. Based on the number of staff that were due to leave at that time, seven midwives were replaced as were one nursing staff member in the special care baby unit, two nursing staff in the emergency department and one obstetrician. The hospital clinically and risk-assessed it at the time, and that was the staffing that was required. There was certainly a dip in staffing levels but these have improved significantly since 2013. We have statistics on that.

I ask Mr. O'Brien to address Deputy Regina Doherty's points.

Mr. Tony O'Brien

Yes. There are also some from Deputy Healy.

I am conscious that it is 5.40 p.m. and we have been here since 11.30 a.m. bar half an hour at lunchtime.

Mr. Tony O'Brien

Is the Chairman's guidance that I should address Deputy Doherty's questions?

Yes. I will leave it up to Mr. O'Brien. I am conscious that there are outstanding questions, but we have been here since 11.30 a.m.

Mr. Tony O'Brien

I am happy to be guided. There was the issue of the 86 families the Minister met last week. I believe Dr. Susan O'Reilly was there also.

Dr. Susan O'Reilly

I was there.

Mr. Tony O'Brien

Deputy Doherty is right. It is a very significant number of people to have had very bad experiences over, I understand, a very long period of time as well as more recently. I understand from the Minister that at least some of those present were relating experiences they had as far back as the 1980s. This is not a new problem and neither is it an old one. It is a problem over a long period of time.

The Deputy asked about the patient safety authority and Dr. Crowley's change of job title. When I appeared before this committee to discuss the 2014 service plan, I outlined some of the changes. I said, "I emphasise there always is a danger, when one has someone who is identified as the director of quality and patient safety, that it could be perceived, either internally or externally, that it is that person" who is responsible solely for quality and patient safety. When the directorate was established which for the first time had people at national level responsible for social care, mental health, acute services and so on, they, as part of their work, accept and take on responsibility for quality and safety in their areas of responsibility. The functions of the director of quality and patient safety were a blend of quality improvement works, such as running the IHI programme for leaders in quality improvement and managing investigations, and a variety of other things. However, they are not actually responsible for the services themselves and therefore are not accountable for failures of service.

Mr. Tony O'Brien

I will continue my answer, if I may, and I will include an answer to that. A bit later in 2014 and partly in response to what had happened in Portlaoise and some of the work that Mr. Ian Carter did, I decided to make a further change to break up the quality and patient safety division, and have one entirely focused on quality improvement activities, which is working with staff around the application of evidence as to what improves quality. Dr. Philip Crowley leads that division while a second quality assurance and verification division which leads investigations, overseas complaint handling, and is changing the way we do complaint handling and operates, if one can use the term, something like an internal HIQA.

In other words, it has a mandate from me to go anywhere and everywhere and conduct its own initial investigations to improve matters. That explains the change in the title.

Who is in charge of it?

Mr. Tony O'Brien

Mr. Patrick Lynch, who is not with us today and who I think I am right in saying took on that role in December. It is set out in the 2015 service plan. It is also a series of changes that have been acknowledged and welcomed by HIQA, notwithstanding the fact, as I acknowledge, that it is still early days. We do not yet know what it will do, but in design terms it is appropriate.

In each of the five divisions at national level it is the divisional national director who has responsibility. In each of the hospital groups it is the group chief executive who has responsibility. In each of the community health organisations which are at a slightly earlier stage of development it is the chief officer who has responsibility. To answer Deputy Seamus Healy's question, a single, national blob-like entity, if I can use that term, that has all of the responsibility at the centre and which is not appropriately diffused is not fit for purpose. As I said in my opening remarks, when I took on the job, it was on the basis that I could make these changes, which are consistent with the programme for Government and the Future Health strategy, in a reasonably timely fashion but only in line with the various policy decisions when made. By the end of the year we will have a much better structure delivery system from the point of view of named people with real responsibility for defined parts of service delivery and others who have more of a commissioning role, which is the long-term intent for how the health service will be organised. I hope I have answered that question.

On the patient safety authority, now more appropriately referred to as a patient advocacy entity, we had done some work, but the Minister will take it forward and establish it as a body or perhaps as part of an existing body which will be in a position to help people to navigate what is, by any means, a very complicated system and act as an advocate in the common sense of the word to ensure there is professional support available to an individual who is seeking redress, information or answers from what is a very large, complex and unwieldy system.

This is not a new question-----

I asked Mr. O'Brien about the apology and if staff had been reprimanded in terms of fitness to practise or whatever else.

Mr. Tony O'Brien

I have apologised publicly before and I am happy to do so again. I have met Mr. and Mrs. Molloy before but not Ms Delahunt or Mr. Kelly. If the opportunity arises before we leave here today, I will also seek to speak to them. I have had some contact with other families in the light of the public apology I made previously who have been remarkably magnanimous in their response.

There are references to the regulatory fitness to practise processes for four staff members. There are others who will be subject to the disciplinary investigation process I mentioned in my opening remarks, the terms of reference for which will be published this week. They have been half-published. They are in what is known as a speedy procurement process because we have to go through a procurement process to bring in senior people from outside the State to do it. They will be finalised and probably by this day next week, everyone will be aware of them and the individuals who will be charged with leading them.

How long will that process take?

Mr. Tony O'Brien

I expect the process to take approximately three months to complete from beginning to conclusion. That is what is in the-----

I am sorry; I did not hear what Mr. O'Brien said.

Mr. Tony O'Brien

I am sorry. I expect the investigation, from commencement to conclusion, to involve a period of about three months. Where individuals are referred for disciplinary hearing, there is a set procedure which will be followed in each case.

At the end of that process there will be accountability.

Mr. Tony O'Brien

Yes. The Health Service Executive's disciplinary code which is consistent with the standards required of a public body has four levels. It has been published and is on the HSE's website. Based on what the investigator finds, the explanations will be put forward by any individual facing a disciplinary hearing. The panel which will hear them will then decide, first, if a case has been shown and, second, what is the appropriate response from an accountability point of view.

Deputies Ó Caoláin, Kelleher and Mitchell O'Connor have indicated. I ask them to limit themselves to one sentence please.

Just one sentence will not manage it, but it is one point. It is the response that Mr. O'Brien gave earlier to my question on the HSE's efforts to close down the "Prime Time" investigation programme. I am reliably informed that every effort was employed by HSE representatives to dissuade the RTE investigation unit from proceeding with its planned programme. HSE voices claimed that nothing untoward had happened. They claimed further that there was nothing unusual whatsoever in the baby death or deaths that had taken place. They attempted to emphasise the normalcy of such child deaths.

Any participation by the HSE in the programme is described to me as reluctant and against a backdrop of persistent discouragement. There may not be a paper trail, but I am told that everything imaginable was employed by these HSE voices to secure a suppression of the programme. If Mr. O'Brien is unaware of that, I would ask him, among all the other things he has undertaken to investigate, to do so in this matter as well. If anyone doubts the veracity of this, it can be verified through appropriate enquiries.

I concur with Deputy Ó Caoláin. The information I have from two different sources corroborates what he has said.

I wish to refer briefly to the question I raised earlier. On page 47 of the HIQA report it says-----

Is this a previous question or a new one?

No, it is a question I raised earlier. I would like an answer to it. I was watching on the monitor and I do not think it was referred to. The report states, in summary, that at the time of the investigation Portlaoise was not resourced as a model 3 hospital, that it was excluded from the smaller hospital framework, and that it was awaiting its role within the hospital group set out by the Higgins report.

It was one of the ten hospitals that were initially identified by the HSE with risks similar to those identified in the Ennis hospital report. Subsequently, it was taken out of the small hospitals framework and included as a level 3 hospital. While that was a policy decision, as I asked Mr. O'Brien previously, at what level or when can the HSE say the policy that is being espoused is just not achievable in terms of patient safety? That is critical. While we have Mr. O'Brien in here, we obviously point the finger at him, but in terms of responsibility, when can he say that he cannot implement the policy because he does not have the resources or it is unsafe, even if the policy dictates he should? Surely there is some line of demarcation on that.

As regards any disciplinary actions, who writes the terms for reference for that? Is it the HSE itself or does it bring in outside individuals, or otherwise, in terms of disciplinary action? The one question I would really like an answer to concerns the issue of Portlaoise and the small hospitals framework.

Ultimately, the HSE representatives are public servants and in that is the hint - the service must be provided to the public. It is always about the public and in every element of that from now on, that should be the clearly defining role of everyone involved in the delivery of health care in this country. Those services are in place for the public, not the other way around.

I ask Deputy Mitchell O'Connor to be very brief because she was in already.

I will be very brief. I want to go back to the questions I asked earlier. I want to ask Professor Greene a question again. I know he explained to me about stillbirth and neonatal birth, and I understand that exactly. I want to go back to baby Mark who was defined as a stillbirth. As far as I know, he still has not been recorded in the statistics. Can Professor Greene assure me that baby deaths will be recorded on the impact notification process?

My second question is for Mr. O'Brien. He said he would apologise to the parents. I want to ask him what exactly he will be apologising for.

I call Mr. O'Brien.

Mr. Tony O'Brien

In the reverse order, if that is okay.

Whichever you want, yes.

Mr. Tony O'Brien

I have apologised for two things. In a number of the baby deaths that were the subject of the HIQA report, there are reports that confirm that there were failings in clinical care. I unreservedly apologise for those.

More particularly what I apologise for are some of the more extraordinary aspects of the interaction that we heard about, including the transportation of remains in the boots of taxis or in a biscuit tin, the lack of candour and the lack of compassion. One of the most egregious aspects for Mr. and Mrs. Molloy was the fact that baby Mark was recorded as stillborn even though we know from the investigation report that he lived for a very short but very significant 22 minutes. I know that weighs very heavily in this process. If that has not been rectified, we will take steps to ensure it is rectified in the registration process.

On the "Prime Time" question, I can confirm that I have no knowledge of any of the matters raised but I will make contact with my counterpart in RTE, who is also called a director general, in order that he can explain the issues to me and we can decide how we can progress them. An earlier question was framed around the issue of legal action, but I am certain there was none of that.

I do not think Mr. O'Brien can be so sure there was none of that. He will have to wait and see.

Mr. Tony O'Brien

Yes, but my current position pending a discussion with the director general of RTE is that such things did not occur. Obviously, I will approach that discussion in an open-minded way.

In regard to the fundamental question raised by Deputy Kelleher, much of this issue played out in a room similar to this one on 21 July 2011. At the beginning of the meeting, my predecessor, Mr. Cathal Magee, included in his opening remarks a number of comments on the implementation of the small hospitals framework, which at that point unambiguously included Portlaoise hospital. The HSE took the view at the time, and still takes the view, that the notion of every hospital fitting neatly into models 1, 2, 3 or 4 is not quite right. These are not written on tablets of stone passed down from Mount Sinai; they are broad descriptions. Portlaoise does not fit terribly well in that it has many of the characteristics of a model 2 hospital and yet it has a very substantial maternity service. In some senses, it is model two and a half, if I can use that terminology. Obviously, it also has paediatrics and certain other attributes. Later on at that meeting, at which it appears from the transcript there was a heated enough discussion, although I was not there, the then Minister made a very clear statement of policy.

The legislation makes clear that it is not for the HSE or any representative attending a joint committee to question the merits of Government policy. The Government makes policies and public servants, as in our case, although civil servants in other cases, are obliged to do their best to implement them. I will not, in any sense, question that. However, there was significant dialogue between the officials of the HSE at that time, and I have seen much of the correspondence and spoken to the officials involved, of whom I was not one, seeking to see how the impact of that could be mitigated in all sorts of terms, bearing in mind that the one thing the HSE did not have available to it at the time was any resource or capacity to do what one might have wanted to do to take it out of the small hospital space and fully supporting it as a model 3, as elaborated. The other big challenge it has is that it does not have the level of activity in a number of areas to sustain it as a model 3 hospital.

What we do next will be done carefully because it is not a simple issue of turning something off and hoping things get better. Sometimes if one stops doing things, the situation gets much worse.

The 24-7 nature of its emergency department is not sustainable, but we cannot simply stop that until we have made alternative arrangements. That takes time. The hospital's critical care unit is not sustainable for a number of reasons relating to the resources available to it and the level of episodes of care which would be necessary to maintain expertise.

As I said in my opening remarks, it is clear in light of this report that the regulator, which has the power to do so, intends to hold to account those who are in our positions at any point in time irrespective of the resources available to us and irrespective of whether the decisions are made by us or in a policy context. Perhaps it was the regulator's intention to bring sharper focus to this. As director general of the HSE, I can tell the committee very clearly that in light of this development and in light of where we are now, we will take a much more robust approach to all these questions. That is going to be painful. Maybe it needs to be painful. We intend to conduct our business in a different way. For example, the submissions we make as part of the budgetary process for the coming year will focus strongly on all the identified risks on our risk register, will have monetary figures attached to them and will be published. This is a watershed in that sense. It has to be. If we are going to be held accountable for political decisions and for the resources that are or are not available to us, as perhaps we should be, we are going to have to embrace that and take it forward in a responsible way.

I will set out what it will not mean. Sometimes this is presented in simplistic terms. It may be suggested that at various times in the past, the right thing to do would have been to withdraw a variety of services from Portlaoise. There is a real possibility that if this had been done, it would have made things much worse in macro terms, taking the entire population into account. We will have to be robust, but that does not mean we will be silly about it. The resources we have are the resources we have. As a result of the economic recovery, the resources we have now are better than the resources we had before. The health service is getting into a better place in that sense. It is very clear that the judgment made in this report is that the HSE should have been much tougher about these things in the past. I think the only response to that is to be much tougher about them in the future.

I thank Mr. O'Brien. I understand Dr. Crowley wants to make a final remark.

Dr. Philip Crowley

Deputy Regina Doherty expressed some concerns about my department. Rather than taking up more time, I will send the Chairman an update on what we are doing at present.

I thank Dr. Crowley for that. In conclusion, I thank Mr. O'Brien, Dr. Henry, Professor Greene, Dr. Crowley, Dr. O'Reilly, Ms McGuinness, Mr. Woods and Ms Fitzgerald for their attendance, their co-operation and, as always, their courtesy. We have had a very long engagement with them. It is fair to say this meeting of the committee has been unique in so far as it has centred very much on the lives of people who have had a huge impact on committee members. I thank all the witnesses for being here this afternoon. It is important for this committee to reflect on the evidence it has heard before it does anything else.

The joint committee adjourned at 6.05 p.m. until 9.30 a.m. on Thursday, 28 May 2015.