National Maternity Services and Infrastructure: Discussion

I welcome our witnesses and thank them for being here. The issue of maternity services is one that the committee had prioritised but, for different reasons, it was put to one side. We are looking forward to our discussion this morning.

I draw the attention of witnesses 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 they 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.

We will hear statements from Dr. Coulter-Smith and Dr. Sheehan, which will be followed by questions and answers. We will then move over to Dr. Foran. Is that agreed? Agreed.

I invite Dr. Coulter-Smith to make his opening statement.

Dr. Sam Coulter-Smith

I thank members for the opportunity to address them today on a subject which continues to be a source of significant public concern. As I approach the end of my term as Master of the Rotunda, I can look back over the last seven years with a unique perspective. This has been the busiest seven years in the 270-year history of the Rotunda. It has been a time when activity levels were extraordinary. The deficits in infrastructure became very evident and the strain and stress on staff was exacerbated by salary cuts. The hospital's ability to deal with these issues was curtailed by reductions in funding allocation and restrictions in head count. The combination of all of these issues has resulted in a significant inability to retain or recruit staff. These staff are a vital arm of our health service. All of these issues, and those I am going to identify today, have had a detrimental effect right across all elements of our health service.

Over the last two to three years, maternity services in Ireland have consistently been in the headlines for all the wrong reasons. There have been numerous high-profile cases reported in the news; multiple investigations with associated recommendations; high-profile coroners inquests; and a variety of HIQA and independent reviews. It has now reached a point where the confidence of the public has been severely shaken and the quality of the services provided to our mothers and babies is questioned in the media on a daily basis. Much of the reporting has been sensationalist and some of it out of context. Such stories are understandably frightening for prospective mothers and families.

To put the situation in context, despite all of the negative publicity, we must recognise that maternity and neonatal outcomes in Ireland remain extremely good and benchmark well when compared to services in comparable countries. Having said that, our results could and should be improving.

There is a normal pregnancy loss rate of between four and seven per 1,000 births of babies greater than 500 grams. Most babies who do not survive suffer from foetal anomalies, extreme prematurity and infection, unpreventable cord accidents or placental dysfunction. Some deaths are unexplained, even after the most detailed post-mortem examination. Only a very small number of normally-formed babies in the latter stages of pregnancy do not survive. It is these preventable situations that we must do our utmost to avoid. It is in these cases that staffing levels, expertise and experience, funding and infrastructure, as well as good clinical governance are so important.

Obstetrics is demand led. Demand for antenatal care and delivery is significantly higher now than it was ten years ago. Some 70,000 babies are born annually in Ireland, which is up from 60,000 a decade ago. In some hospitals, delivery numbers are up between 25% and 30% over ten years. I know what that means, as will my colleagues here, but for the layperson they are just numbers. To put these figures into reality, as a hospital with nine delivery rooms and about 9,000 deliveries annually, we have between 25 and 45 births every day. That means that each delivery room is used between three and five times a day. Considering that the average duration of labour for a first-time mother is between eight and ten hours, those numbers just do not add up. This puts too much strain on our facilities and staff.

Ireland had the highest birth rate in Europe between 2004 and 2013, yet we have the third lowest number of consultant obstetricians per 100,000 women in the population, among 34 OECD countries. In order to reach accepted, recognised international norms, we need to increase our consultant numbers by 57% and we need an additional 600 midwives.

In 2003, the Hanly report recommended an increase in consultant numbers. Specifically for obstetrics and gynaecology, a target of 179 consultants was set for 2009, to go up to 191 by 2013. By the end of 2014 we only had 133, despite deliveries being up by 30%. In 2006 the Institute of Obstetricians and Gynaecologists recommended 24-hour on-site cover in the bigger units. A figure of one consultant for every 350 deliveries was recommended. This would require the current number of consultants to be increased by 57%. The KPMG report in 2008 recommended an expansion of consultant numbers. HIQA, in Galway in 2013, said there was a relatively low number of consultant obstetricians in Ireland.

That is more than ten years of reports saying exactly the same thing. I am not sure how many more investigations, reports, and recommendations are required - or how many more adverse events will be required - to get those who oversee and fund the health service to recognise the need to invest in the quality staff required to keep our mothers and babies safe.

The complexity of the patients we deal with has become a serious issue. Obesity now affects approximately 30% of our patients and, by extension, there is increased risk and cost. Unusual and resistant infections are now much more frequent and women with complex co-morbidity now conceive, requiring multidisciplinary care across several services. Population diversity has brought challenges, with new disease entities and greater social and communication issues. Despite all these challenges, results have remained good but our staff and infrastructure are strained by these extra demands. Crucially, no additional funding has been put in place to deal with these issues.

With regard to funding, we know that maternal and perinatal mortality rates income when Government funding reduces, yet between 2009 and 2012, the busiest time in the history of modern Irish obstetrics, when activity levels were up by 25%, spending was cut by 3.5%. The recent recession has caused a reduction in fee income for our voluntary hospitals and these fees account for approximately 20% of our budget. This fall in income has worsened our funding deficit. We had opportunities to co-locate and, unfortunately, these opportunities were missed. None of our three major maternity hospitals has immediate access to intensive care facilities for adult patients and sick mothers are still transferred by ambulance to adult hospitals away from their newborn babies. Access to appropriate imaging, such as CT and MRI, has to be organised off site and access to joint services and multidisciplinary team care requires complex agreements between different hospitals on different sites and sometimes in different groups. All of these factors combined have resulted in all hospitals having difficulty retaining and recruiting quality staff. The exodus of our excellent trainees to more attractive packages abroad continues, resulting in an over-reliance on locum and agency staff. This drives cost up and quality down and is no way to run a health service.

In recent years the HSE set up clinical programmes in most specialties, which have assisted greatly with the provision of national clinical guidelines. This was a welcome development. Unfortunately, however, there was no provision of additional resources to allow some of these best practice guidelines to be put into action. Many hospitals do not have the infrastructure or the staff to implement such guidelines. Despite the availability of good, solid information on where staffing levels should be, no effort has been made to bring levels of staffing up to recommended ratios. Better incident reporting has assisted with improved knowledge of clinical incidents but without the factors identified above being addressed, it is difficult to see how we can improve the position. The new one-size-fits-all incident reporting form currently being trialled in conjunction with the State Claims Agency is not working very well or gathering the sort of vital information that we need to improve our services.

I will speak to inequality of access to services. Patients in different parts of the country do not have equity of access to subspecialist services and, for example, anatomy screening scans at 20 weeks' gestation are only available in bigger centres. In the tragic situation where a baby dies, only in the bigger hospitals will a dedicated bereavement team be called in and a dedicated perinatal pathologist be available to carry out a post mortem and get the best information as to what may have been the cause of death. This is really important information for the family and clinicians. Mental health issues in pregnancy affect approximately 10% of patients, yet services and staff for these patients are deficient. Endocrine services for diabetic and thyroid patients are stretched beyond coping point, and this should be addressed.

With respect to governance of services, historically, State-owned HSE hospitals report directly to HSE. Maternity units in HSE hospitals, therefore, have no direct governance relationship with the HSE, as it goes through the management system, and the performance indicators set for those hospitals by the HSE do not and never did relate to maternity services or their outcomes. This lack of direct oversight and a reporting relationship which was not designed to identify clinical risks have led to either failure to respond or delayed response to clinical issues. This lack of good governance in some hospitals has been pointed out in several recent reports. Even in voluntary hospitals such as ours, where clinical governance systems are tighter, we have still had great difficulty escalating some of our concerns. The theme is consistent, as clinicians raise concerns, governance systems are not good enough to ensure these issues are acted upon and nothing changes until something bad happens.

The oversight and running of our health service is currently undergoing another transition. The country has been divided into regions, with each one serviced by a hospital group based around an academic partner. The groups have been very slow to evolve. The appointment of chief executive officers has also been slow and these were meant to have boards to report to but they have not been appointed. The delay in driving this process carries the risk of leaving a vacuum at a governance level, particularly for the non-voluntary hospitals. This vacuum creates a dangerous lack of oversight and needs to be addressed urgently. How the voluntary hospitals fit into this new group model has not yet been worked out. The Minister has indicated that he sees voluntary hospitals, particularly the maternity hospitals, playing an important role in the new groups, and we welcome his reassurance, although it is unclear how this is going to work. There is a real fear that in the current proposed model, the voluntary sector, which has contributed so much to the development and improvement of our services, may be threatened by extinction. This, in our view, would be a very retrograde step for maternity services.

Ireland has a reputation for high levels of medico-legal claims and obstetrics is a high-risk specialty. Approximately 20% of claims arise from obstetrics and midwifery practice but this accounts for 60% of the monetary value of claims. This amounts to approximately €60 million annually, enough to run one of the Dublin maternity hospitals for that period. The State Claims Agency deals with this and shares information with individual hospitals but there is no national learning from this valuable information.

With regard to models of care, all women, regardless of their risk categorisation, should be entitled to the best possible facilities and one-to-one midwifery care, with access to medical information as required. There has been much discussion around models of care and some very vocal groups are suggesting that midwifery-led models are better. The delivery of maternity services requires co-ordination of both midwifery and medical obstetric services and it is impossible to separate these two functions because low-risk women can become high risk with little warning; therefore, in most developed countries, care of women in pregnancy is shared between these two professional groups. The important issue is that all mothers should have access to the best possible facilities in the most relaxed surroundings, with good continuity of care, and be looked after by midwives experienced in both normal and complex labour. Women who remain low risk can be delivered by those midwives and those who become more complicated can retain their continuity of care with that midwife but responsibility moves seamlessly to the medical team. There should be no need to move a patient in labour to a different location and continuity should be maintained.

If we genuinely want patient-centred care, we need to get away from the idea that one professional group has ownership over pregnant mothers. The terms "midwifery-led care" and "medically-led care" should be abandoned because they put the professional at the centre and not the patient. All patients, regardless of their risk category, should be able to access the best possible care and medical expertise required for delivery in comfortable surroundings. Care based on patient need is required. There is no doubt that antenatal care to low-risk women should be delivered in a community setting, as this would cut out long waits in hospital outpatient clinics and allow hospital services to be devoted to higher-risk patients. There needs to be significant investment in these community services to promote this model.

The current protection of life in pregnancy legislation is welcome. It puts some structure and guidance around what to do when a woman's life is at risk. However, that particular legislation does not assist us when faced with a woman carrying a baby with either a fatal foetal abnormality or one where the anomaly is life-limiting. Ideally, most obstetricians would like to see legislation that would allow us to support women and their families in whatever decision they make regarding their pregnancy in such a difficult position. Where a woman chooses to continue the pregnancy, we need to be in a position to support her choice with appropriate facilities and services for her unique situation.

Having identified some of the issues that need to be tackled, I will make some suggestions to the committee and the Minister to assist in improving the quality of services and help restore confidence in our services. I hope these suggestions will help to inform the work and output of the new national strategy group. First, we should set up a clinical governance system in each of our maternity units to oversee clinical activity, with appropriate clinical audit, clinical risk reporting and incident review to allow units to benchmark against each other. This system should mirror what currently exists in the Dublin maternity hospitals, where a clinician leads the service and is accountable for its provision. Second, each unit delivering maternity services should have a sufficient critical mass of activity to support the full range of services required to deliver that care to the population it serves. We believe this is approximately 4,000 to 5,000 births annually. This may require examining the models of care provided in some units or the provision of satellite clinics in some areas. These decisions can be made on a needs assessment of care. Third, each unit should have facilities to provide care for a full range services to deal with all levels of complexity, from the normal midwife model to the more complex medical model, with seamless transition between the two, again based on patient needs.

I have already mentioned the terms "midwifery care" and "obstetric-led care" being abandoned and moving to a patient-centred care model.

Low-risk patients should be looked after by midwives based more in the community, where possible, and hospital clinics should be preserved for the more complex patients. The midwives delivering the community-based care should rotate through the hospital at intervals to maintain their skills, keep up to date with guidelines and stay familiar with current practice.

We need a well-organised and fully resourced national transport system to build on what currently exists to allow transport of mothers and babies to an appropriate setting when required. Our tertiary referral maternity centres should be co-located with acute adult hospitals which can support the requirements of the high-risk patient. With access to intensive care and radiology services, stand-alone maternity units should be a thing of the past.

Our maternity units should be staffed to a level commensurate with accepted international standards. This was recommended in the KPMG report in 2008 and a variety of reports stretching back to 2003 but has never been acted. Failure to provide appropriate working arrangements for highly-skilled and motivated staff will lead to further worsening of the current manpower crisis. The staff of the health service are its most valuable asset and need to be treated as such. Pay and conditions need to be restored to a level where we, as a country, can compete with services in other countries. We still have one of the lowest midwife and consultant ratios in the developed world.

In moving toward the hospital groups, any governance system we put in place should recognise the value that voluntary hospitals have given in the development of our service and foster the values and ethos of these institutions. The valuable work led by the national lead in the production of national guidelines needs to be accompanied by resources to allow their implementation. This issue has not been addressed adequately.

The maternity services need to have access to the State Claims Agency's information relating to adverse incidents and claims. This hugely valuable information would allow clinical issues and trends to be identifiable, benchmarked and highlighted and appropriate interventions to be made possible. This information would need to be monitored in an agreed way possibly through the national lead and clinical programmes. This data will be sensitive. It, therefore, needs to be anonymised and appropriate confidentiality measures need to be put in place.

Dublin’s three maternity hospitals cover almost half the deliveries in the country. We believe we have a unique perspective and valuable experience to offer. While we accept that each of our hospitals has from time to time been involved in cases and issues where outcomes could and should have been better, we believe that through good governance and oversight, we have responded to those issues and put systems in place to improve the quality of our outcomes and the service to our patients. We not only benchmark against each other but also internationally. We believe our systems are robust and should be replicated across the country.

Above all, our health service is our staff. They are our most valuable asset and we urgently need to put measures in place to retain them. Failure to address the already acute staffing issue has started to affect the quality of services we provide and will ultimately lead to a worsening of outcomes, more adverse events and bigger medical, legal and litigation issues. Doing nothing or token gestures are not sufficient. We need a strategy to repair the damage that has been done in recent years.

I now call on Dr. Sharon Sheehan to make her opening remarks.

Dr. Sharon Sheehan

I thank the Chairman and members most sincerely for inviting me to give evidence on the future of maternity services in Ireland. I would like to start by introducing myself. I am the Master and CEO of the Coombe Women and Infants University Hospital, the largest provider of women and infant health care in the State. Last year, we delivered almost 9,000 babies. As well as being CEO, I am a consultant obstetrician and gynaecologist and have trained in both Ireland and the UK. I am a member of the executive council of the Institute of Obstetricians and Gynaecologists, a member of the Royal College of Physicians of Ireland and a member of the Royal College of Obstetricians and Gynaecologists in the UK. I am also a member of the national maternity strategy steering group, representing the joint standing committee of the Dublin maternity hospitals.

In looking at our maternity hospitals, we must remember that, thankfully, the vast majority of pregnancies result in a healthy mother and baby. We are on the verge of producing the first ever Irish maternity strategy and we must ensure that each child is given the best start in life while endeavouring to make the experience the best possible one for the mother. Ireland demonstrates one of the highest fertility rates in Europe and despite a recent small decline in the national birth rate, the maternity services are under increasing pressure. The complexity of mothers attending for antenatal care is ever-increasing.

Significant increases in rates of obesity, gestational diabetes, assisted reproduction and coexisting medical problems coupled with advancing maternal age continue to pose enormous challenges for obstetricians, midwives and other allied health professionals. Poor social circumstances and, more recently, homelessness, are adding to the complexity of patient care. Advances in neonatal care, particularly at the threshold of viability and the therapeutic cooling of the full-term infant to prevent cerebral palsy, are great success stories but the intensity and acuity of the workload must be recognised and resourced.

In recent years, maternity services have rarely been out of the media spotlight. Much work needs to be done to restore public confidence in our maternity services. We must acknowledge what is working well and what needs to be improved. When we look at maternity services, we cannot ignore gynaecology. Gynaecology is provided in all of the 19 maternity units throughout the country. Following the very successful introduction of the national cancer control programme, the increase in benign referrals transferred to non-cancer services spiralled out of control in the absence of resources. Waiting lists for gynaecology outpatients are wholly unacceptable, often exceeding 18 months, but we simply do not have the staff to bring down these numbers.

In respect of quality and patient safety, perinatal death rates continue to decline and maternal death rates are among the lowest in the developed world. Despite the low rates, we cannot become complacent. A death is a tragedy and we must learn from it and drive improvement and change. From the most recent confidential inquiry into maternal deaths across Ireland and the UK published in December 2014, we know that the majority of women who died during or after pregnancy died from indirect causes, that is, from an exacerbation of a pre-existing disease. Three-quarters of the women who died had medical or mental health problems before they became pregnant. We must plan for the care of women with known medical complications, particularly before they become pregnant, and also during their pregnancy. Only one third of women died from direct complications of pregnancy such as bleeding.

A spotlight has been shone in the past decade on severe maternal morbidity as an important quality indicator of obstetric care and maternal well-being in high-resourced countries. Learning from morbidities is really important - looking at what went wrong and what went well. One of our colleagues, Dr. Michael Geary, refers to "great saves" rather than "near misses" - recognising when patients have received exceptional care and when this care has averted an adverse outcome. Review and oversight in respect of the provision of high-quality maternity services are really welcome. Each of the three Dublin maternity hospitals produces annual clinical reports which are not only published but externally assessed and peer reviewed each year. In addition, each of the 19 maternity units submits data relating to patient safety and quality of care to a number of national agencies for review, including the State Claims Agency, the National Perinatal Epidemiology Centre and the quality assurance programme of the HSE clinical care programme in obstetrics and gynaecology. These allow assessment of performance over time, but even more importantly, they allow us to benchmark our performance against other similar units nationally.

In designing models of maternity care for the future, the principles of access, equity, appropriateness, effectiveness and value must be considered. All women should expect and receive high-quality, safe care delivered in the most appropriate setting by the most appropriate care provider based on the needs of the woman and her baby. Care must be patient-centred and evidence-based and allow the patient choice. In Ireland, most maternity care is hospital-based. Much of this antenatal and postnatal care could and should be delivered in the community. Community midwifery services in Ireland are patchy and are largely confined to the Dublin maternity hospitals, allowing the woman to access care close to home and, most important, permitting continuity of care, usually with a team of midwives.

It is not surprising that demand for these services is increasing. A nationwide solution must be put in place to resolve this issue.

Collaboration and teamwork are essential for the delivery of a safe and high quality maternity service. Too often we get lost in debates on midwifery-led care versus consultant-led care, high risk versus low risk, consultant-led units versus midwifery-led units, or alongside midwifery-led units, or stand-alone midwifery-led units, and home birth versus hospital birth. If we revert to the principle of what a woman and her baby or babies need and providing that care, then the pathway becomes much clearer. Every single woman, irrespective of her risk, deserves midwifery care during pregnancy. Clinical care pathways facilitate the seamless transition of a woman across health care providers and services based on her needs at a particular time.

In looking at models of care it is important to define standards. At present the standards of care throughout the country are inequitable. By way of example, international best practice recommends that every mother has a scan early in pregnancy to confirm her dates and again a little later to assess any foetal problems. These standards are only being delivered in a handful of maternity units throughout the country which is wholly unacceptable.

The promotion of normality must also be balanced with the need for escalation in the event of an obstetric emergency. It is important to define levels of care and determine what level of care should be provided in each hospital. It is completely inappropriate to suggest that all maternity units should be able to offer high-tech intensive care facilities, but we must guarantee and ensure there is streamlined access to critical care at a time when it is most needed. The national neonatal transport system is a great example and has been hugely successful. It aims to provide all neonates who require critical care transport with access to a dedicated, highly professional and equipped team that is available at all times of the day or night. A similar programme for in utero transfers is urgently required. Both of these transport systems must have dedicated and ring-fenced funding.

In terms of the staffing of maternity services, an integrated approach to workforce planning is required. In addition to midwives and obstetricians, a host of other specialists and specialties interact with the mother or her baby during their time in maternity service care. They include neonatologists, anaesthetists, general practitioners, perinatal mental health physicians, perinatal pathologists and other allied health care professionals. Therefore, investment in staff is paramount. We have a highly skilled and talented workforce in Irish maternity services. Internationally our doctors, nurses and midwives have always held the reputation of being the best educated and trained, so it is not surprising that other countries look to our highly skilled doctors, midwives and nurses to staff their maternity units.

Staffing levels in maternity services in Ireland are a major concern. The lifting of the moratorium in HSE hospitals has resulted in a significant movement of staff away from voluntary hospitals. More recently, financially rewarding and attractive packages offered in the Middle East have attracted our highly trained and skilled staff. Of greatest concern to me are the unfilled places on the bachelor of midwifery university degree programmes and the higher diploma of midwifery programmes.

A recent study, entitled Birthrate Plus, reviewed the appropriate staffing levels in Irish maternity units. I understand that the funding requests for the additional posts deemed necessary to achieve minimum staffing levels have been made to the Department of Public Expenditure and Reform. Such funding must be approved but we need a robust national recruitment strategy to attract midwives to take up these posts.

Our hospitals continue to face ongoing challenges in terms of the European working time directive for non-consultant hospital doctors. There are insufficient numbers of NCHDs working in maternity services to achieve compliance. The 20% reduction in training time that would result from a 48-hour week has not been adequately addressed.

Last June a supplementary report on consultant workforce planning in 2015 was published by the HSE's national clinical programme for obstetrics and gynaecology. It showed that Ireland has the lowest number of obstetricians and gynaecologists per 100,000 women and the lowest per 1,000 live births of all OECD countries. The report states that there is somewhere between 120 and 140 consultant obstetricians delivering services in our maternity units. It recommends that an additional 100 new consultant posts are required to bring us in line with our UK counterparts. Promotion and integration of education, training, research and innovation are essential components of high quality clinical care and should be included in all clinical strategic considerations and planning.

In terms of governance, all women should have a clearly identifiable lead health care professional. We need to realise that patient safety is not only a clinical responsibility but is also a corporate responsibility. Any model of care proposed must be founded on the principles of good corporate and clinical governance and have a strong leadership to drive clinical excellence, quality, safety and clear accountability. I firmly believe that the mastership model operating in the three Dublin maternity hospitals works extremely well and should be maintained and expanded to the hospital groups.

In terms of systems, there is wide acceptance that teamwork and good communication are essential, but there is increasing evidence to suggest that systems can either obstruct or support collaboration. Therefore, organisational design must support effective collaboration.

Kofi Annan has said that knowledge is power and information is liberating. Therefore, investment in information technology is essential. Many of the 19 maternity units have no ICT system whatsoever and data must be collected manually. At present, data are collected through the national perinatal reporting system and the hospital inpatient enquiry scheme, HIPE. More recently, the Irish maternity indicator system has begun to collect data which highlight the lack of consistency across the different systems. I welcome the new maternal and newborn clinical management system which has an expected roll-out date of early 2016 to four of the 19 maternity units.

Ireland has an international reputation for quality research on maternity services. Advances in medical research and technologies must be supported. Maternity care in the future is likely to involve early innovative screening for biomarkers to detect pregnancies that are at risk of potentially life threatening conditions such as pre-eclampsia and other pregnancies most at risk.

In terms of funding, our maternity units have suffered from chronic under-investment. Numerous reports and recommendations for improvements in quality and patient safety have been produced but never funded or implemented. We cannot allow this cycle to be perpetuated. Maternity is a demand-led specialty, there are no waiting lists and we cannot cancel clinics or close wards. In addition, our emergency rooms are neither recognised nor resourced. There is a lack of transparency about the funding mechanism for our hospitals. I welcome the new funding models of activity-based funding and money follows the patient. However, historical under-funding and deficits which have accrued over the years must be addressed if we are to move forward.

In terms of location and our facilities, maternity facilities must be fit for purpose with infrastructure that is appropriate for clinical needs. It is inappropriate to have bereaved mothers sharing a room or a ward with newborn babies. It is inappropriate to have mothers who are miscarrying sitting alongside mothers with buggies while waiting for hospital appointments. That is what is happening to some mother as we sit here at this committee. Funding for the business cases to redevelop our units must be prioritised and made available in advance of any proposed relocations in order that we can deliver a humane service to mothers.

To summarise, the national maternity strategy along with all of the other reports must not be allowed to sit on bookshelves gathering dust. The strategy will only be as good as the plan designed to implement it.

We have a poor track record of implementation of reports and recommendations and I urge the Minister for Health, the Department of Health and the HSE to prioritise, fund and support the full implementation of this strategy. If I could leave the committee with just one message today, it is that investment in our maternity services, namely, investment in models of care, technologies, equipment, facilities and, most important, our staff, must be prioritised.

I thank the committee for giving me the opportunity to present my views today and look forward to answering any questions the committee might have for me.

I thank the two masters for their presentations. Reference has been made to the fact that in recent years there has been some high-profile and tragic incidents in our maternity services. There is always the concern, in reacting to such adverse events, that we have a very short-term response and no strategy that flows from it. We have a knee-jerk reaction rather than putting in place a proper strategy that would deal not just with an adverse event but which would also bring forward better maternity services. In that context, it was mentioned that we have 19 maternity units in the country serving a population of 4.5 million. Whatever way it is calculated, 50,000 to 75,000 births will probably be the going rate for the next number of years. As the population ages, there probably will also be a drop in birth rates. We should bear all that in mind as well as the fact that when, as I always say, medicine and politics meet, seldom there is a good outcome. That is often the difficulty in this country. We consistently politicise our health services. If a decision is made by a Government or Minister, the medical professionals become political. We do not seem to have proper discourse or debate about what is right for the patient.

When talking to professionals of all hues, colours and backgrounds, I find that sometimes the patients' concerns are very much secondary. The professionals and politicians sometimes put their own profession and concerns ahead of those of patients. It is not done in an underhand way; it is often just the nature of the beast. Between now and the publication of the review of the maternity services, which is urgently required, are we capable of coming up with a blueprint and planning our health services and maternity services in the short and medium term?

Dr. Coulter-Smith and others referred to community-led midwifery and maternity services. To many that means the local maternity hospital is closing down and getting those discussions going in communities can be very difficult. It was said that approximately 4,000 to 5,000 births per annum is the best ratio to maintain competence, continuing professional development and medical expertise, but many hospitals have fewer than 4,000 births. There will be many around this table and elsewhere whose maternity hospital in their constituency or region has only 3,000 births, which means closure. When developing a strategy, we need to come at it purely from the point of view of patients. I mean that with respect to everyone in this room. We have made this point in debates on foot of tragic circumstances that have received national and international attention, yet the system trundles on. We need to follow through on commitments we make. I am not putting questions but making points because many important people are here today.

When we talk about reviews, restructuring and reconfiguration of maternity services, it is normally done as a pretext to a downgrading of services. We should be honest about that fact. Over the history of our health services, when we have spoken about reconfiguration and amalgamation, they have often been a result of cuts to capital projects, funding and current expenditure. However, we not have a huge opportunity to get maternity services right.

At the end of that Second Stage speech, Chairman, for which I apologise, I have a couple of questions. We often compare ourselves to the UK when we look at statistics and best practice in maternity services, and rightly so, but given the geography and size of our dispersed population and the fact we have one large city and pretty much after that small regional towns, apart obviously from the city in Cork as well, for fear I would forget it, where else could we look? Where else should we look to get a blueprint for the building of good community care, midwifery-led services and high-end centres of excellence attached to tertiary hospitals? Where else should we look for a blueprint to do all the things we need to do?

I join the Chairman in welcoming our panellists and thank Dr. Coulter-Smith and Dr. Sheehan for their presentations and for circulating the broad text of their contributions earlier. I have a number of questions although none is directed at any of the witnesses in particular. As they are comfortable, they might please respond.

On adverse outcomes, the accepted but unacceptable situation is to deny and defend. Do the witnesses, in their respective positions, believe a change of approach is needed to this disposition, which is very much in situ? Do they believe that not only their profession and the provision of maternity services but the broader public interest would be better served by an acknowledge and apologise approach? Do they and their colleagues believe they have a role to play in bringing about a change in the approach of the State Claims Agency in this respect? I think we all recognise that if one were to act individually, as I have urged, the State Claims Agency would go ballistic, as it were.

I will direct a specific question on inquiries and investigations to Dr. Coulter-Smith. My personal noting of inquiries and investigations is that they are mainly carried out by senior consultants and practitioners engaged by the HSE or hospital management. These people are the busiest of our practitioners. They are people such as Dr. Coulter-Smith, who is himself the master of a maternity hospital. As he is so busy, the consequence of having him on a panel set up to carry out an investigation in another hospital on a particular adverse outcome would be that there would be an inordinate delay in the conduct of the process and the publication of a report and recommendations. In my constituency of Cavan we have one maternity hospital. Currently, five maternity related reports are awaited. It is not the fault of those panellists that in one particular instance we are almost at the three-year mark and still waiting for something to enter the public arena.

I wonder if Dr. Coulter-Smith is engaged in such work. If he is, how many is he currently involved in and how many over the seven years of his holding the position of master of the Rotunda would he have been directly involved in? Does he think that is appropriate? Is that good use of his time? Would the process be better served by more available clinicians - I do know at what point in their service that could even be viewed as right - or perhaps retirees? I would be interested genuinely in knowing what his views are in relation to that. I would add that knowing some of the perils concerned and knowing some of the excellent staff in these maternity settings, including in Cavan, I can affirm the pain and hurt, not only of families but of those who provide such excellent service beyond the line of duty, at the delay in having the facts established. It is a terrible disservice to excellent doctors, nurses and support staff in the maternity settings. We need speedy address of these matters.
I note and welcome Dr. Coulter-Smith's remarks regarding the need for legislation that would provide for interventions in cases of fatal foetal abnormalities where such an intervention is the wish of the pregnant woman.
In relation to models of care, Dr. Sharon Sheehan referred to community midwifery services largely confined to the Dublin hospitals. Is it the case that in the Coombe and the Rotunda women do not have the choice between consultant-led, medically-led birthing opportunities and midwifery-led ones? They do not exist in either of the two major hospitals. Indeed, my understanding is that they are available only in two maternity settings across the State and both of them are in the RCSI region, close to my domicile.
The Chair might bear with me for one moment. On staffing levels, I agree with the point Dr. Sheehan made and thank her for so much of what she included in her contribution today. We talk here in terms of the lifting of the recruitment embargo and we note the failure of the bring-them-home campaign - I do not see a big flood coming home - but Dr. Sheehan stated that the lifting of the moratorium in HSE hospitals has resulted in the movement of staff away. Could she explain that moratorium reference and the impact of it? I am a little puzzled. I enjoyed the point about there being no waiting lists and that clinics cannot be cancelled nor wards closed. How true that is. It is a pity it did not apply in all settings across the health services.

I thank Dr. Coulter-Smith and Dr. Sheehan for what were really very detailed presentations. As I said as late as last evening in the Chamber, I acknowledge the background not only to the maternity service but to the health service is that we have lost €4 billion in funding, 11,000 staff and 2,000 beds in the past number of years and, on top of that, there has been the moratorium. Of course, that was on top of a situation where most services were not well staffed anyway and certainly services outside Dublin were much less well-staffed than the Dublin services, and even those were not properly or fully staffed. Obviously, that is the background and one that I absolutely accept.

I have a couple of questions. The first question is for Dr. Sheehan and relates to the statement, which I fully acknowledge, that much of antenatal and postnatal care should be provided in the community. I absolutely agree with that. I would like if Dr. Sheehan would explain to us exactly what that would mean, how that would work in practice and what level of service could be expected and provided in the community.

I would like to ask Dr. Coulter-Smith from where the figure for the cut-off point of 4,000 to 5,000 births annually is coming. I am around quite a while and I have seen that figure vary over the years. I have never seen it as high as 4,000 to 5,000. Certainly, in many of the maternity units of our EU partners, it would be considerably lower than that. I wonder from where that figure came. Even if the lower figure of 4,000 birth were to be implemented, what, in practice, would that mean for the 19 maternity units around the country?

I welcome the witnesses and thank them for their comprehensive presentations. Many of the issues they raised this morning are ones I have highlighted over the past four years. In terms of some of the issues, it is like banging one's head against a stone wall. Dr. Coulter-Smith raised the fact that the number of consultants is 133. The Hanly report stated that over 170 consultants should be appointed. The Hanly report dates from 2003 but very little progress has been made. Dr. Coulter-Smith gave the figure of 133. I understand that whole-time equivalent consultants number 114. Therefore, we have moved from 93 consultants in 2003 to 114 and at the same time, we have had a significant increase in the number of deliveries and very little response from within the system as regards sanctioning additional posts. Even if one wanted to recruit an extra 20 consultants in the morning, what kind of difficulties would we face in trying to recruit that number of consultants in a short time period and what do we need to do to make it attractive for consultants to come back to Ireland to provide the service required?

The second issue follows on Deputy Ó Caoláin's issue in relation to inquiries. I also have a concern about that issue where there is a delay in dealing with inquiries. Is there a need to set up a better structure for dealing with inquiries than what we have at present because each hospital seems to be dealing with them on an individual basis rather than in a co-ordinated way? Should we have a set system in place for all of the hospitals because I am a little concerned about the delays? The immediate reaction of those involved is that there is a cover-up going on. The next step is litigation and then there are considerable complications thereafter.

The other issue I want to raise is about the coverage. Dr. Coulter-Smith referred to the amount of adverse coverage of the maternity services. In relation to the effects it has on staff in the maternity units, is there any back-up supports for the staff who have worked to the best of their ability in delivering the services? The focus is very much on the hospital and its staff when something goes wrong and that obviously has a knock-on effect on staff and on their performance. Is there enough backup support for staff where something goes wrong?

I recently came across a case where something went wrong. While it was no one's fault in real terms, the staff member wanted to resign the following morning. Someone had to sit down with them for three to four hours to try to talk them through it. It was an issue out of their control. Do our hospitals have enough support for the staff where an adverse outcome occurs?

I thank the witnesses for their in-depth statements. The report covered a wide range of issues and I found parts of it very bleak and challenging. The witnesses spoke about a well-educated staff and people being enticed to work outside the country. Some staff have told me they have not only left because they want to go away but because they want to become consultants and find it very hard to do so here and have to go away and do many other things before they can come back, so I suppose getting on the rung of the ladder is important.

The witnesses spoke about the historical reporting of maternity care in the country. It is an historical thing. As the witnesses said, there are many holes in the system, but that has not just happened in recent years. For a long time there has been a lack of joined-up thinking and a lack of funding.

I believe in the idea of the co-location of hospitals and particularly training hospitals. I ask Dr. Sheehan for her views on the proposed location of the new national children's hospital on the St. James's Hospital campus and the proposed location of the Coombe Women and Infants University Hospital on that site. It probably will not happen very soon. I would be interested to hear her thoughts on that given that I live quite close to it.

I am the mother of four girls, three of whom have babies - I have three grandchildren. During all their pregnancies they got excellent care in the community from their GP and particularly from the local nurses, etc. The idea of visiting the hospital and then visiting one's community care is very important. I agree with the witnesses that if we are to help people, particularly in the early stages of pregnancy and particularly young people right across the board, regardless of whether they have medical issues, it is the place to do so. It is very important to invest heavily in community care.

As a mother, I know that going into labour for the first time is a terrifying experience. In the long run when a pregnant woman goes in behind the hospital doors she is completely in the hands of the staff and dependent on the quality of staff. It is not always about the medical care, it is about people just being there for her and doing the normal things that nurses do such as holding her hand and bringing her through the stages of her pregnancy. We do not appreciate the quality of the people in hospitals, not just nurses but other people working in the hospitals even down to the people who give out the tea in the evening. The camaraderie they show in speaking to people and looking at the babies is very important. In that respect, I believe our hospitals are unique.

My only question was on co-location and the possibility of the Coombe Women and Infants University Hospital being located on the site. I thank the witnesses for taking time out of their busy schedules to come here and present to us. I will go away more enlightened this morning. I am a member of a Government party and we certainly have not fixed many things in health. However, I think we are going in the right direction when we have reports such as this and we can understand what people have to deal with in hospitals, particularly the witnesses.

I apologise for being late. I compliment our maternity services in general. As Deputy Catherine Byrne has said, the whole system from when a pregnant woman attends her first appointment to the delivery of the baby is excellent. The care that is given in maternity hospitals by midwives, obstetricians, gynaecologists and others is outstanding. As outlined in the presentation, half of all babies born are born in Dublin, but I want to praise the services in the west and north west.

It is very important that the obstetricians and gynaecologists have the expertise that is needed in the case of rare diseases. I am speaking for myself because when I was pregnant I got acute fatty liver disease, which is a very rare disease. I know I am extremely lucky to be here, which is because I was looked after very well by one of our top gynaecologists, Meabh Ní Bhuinneain, who is completely dedicated to her job. She is always furthering her career and is deeply interested in maternity services. Her registrar, who had worked in many big hospitals - I think, in New Zealand or Australia - had seen the disease previously. While I know complications in pregnancy are rare, dealing with them appropriately is important.

Sligo General Hospital and Mayo General Hospital have two outstanding maternity units. As a woman and a mother, I am very proud to have been looked after so well in the west.

I call Dr. Coulter-Smith.

Before Dr. Coulter-Smith starts, I want to apologise. I have to chair another all-party meeting on mental health which will start in a couple of minutes. I ask the witnesses not to interpret my leaving as any rudeness.

Dr. Sam Coulter-Smith

I will address Deputy Ó Caoláin's questions first. Adverse outcomes are tragic. They are of huge concern to us when they happen. They are obviously major life events for all the people involved. They are very difficult and very time consuming. In addition to the grief there is often anger and many issues need to be dealt with. The key to dealing with adverse outcomes is to keep lines of communications open, to embrace the idea of open disclosure, and to have a bereavement team that is able to come and sweep up the situation and get everything organised so that no issues are left unsorted. There needs to be open disclosure and an open door policy so that people can communicate and those lines of communication need to be with senior clinicians and senior midwives. That is why Dr. Sheehan mentioned the idea of a lead person involved in everybody's care.

We also need to have perinatal pathology. Our submissions mentioned that perinatal pathology is not available everywhere. That is a very important part of the jigsaw for patients. Timely post-mortem examination with timely results keeping those lines of communication open with patients is a really big part of successfully dealing with an adverse outcome.

The coroners' system is slow. Getting information back from coroners can often take months. The more time that is left before making contact with patients and getting them back to give them results is time for them to dwell on what has happened. We need to keep those lines of communication open in the intervening time and we need that process to be as speedy as it can possibly be.

I have not personally got involved in external reviews; I am far too busy doing what I do on a daily basis to do that.

Often, such reviews are done by senior clinicians who filled my role previously, that is, ex-masters of the maternity hospitals. Success in dealing with an adverse outcome lies with communication, bereavement teams, perinatal pathology and open disclosure. We in the Rotunda have embraced this approach completely. We are open with patients when things go wrong. There will always be situations that are difficult to deal with but, in the majority of those, patients are grateful when one is open and honest with them.

Is there a particular reason for the delay with the coroner? Could it be averted?

Dr. Sam Coulter-Smith

I am not sure. It may be pressure of work, it may just be that the system is a little slow. It would assist us greatly if those types of cases could be turned around more quickly. We have a good relationship with our coroner. We are able to lift the telephone and talk. If we need to give results to patients, he is often amenable to doing so. This may not be the case across the country. I do not know.

Regarding Deputy Kelleher's question, we often have knee-jerk reactions to adverse events. This is unfortunate, as we need a considered approach. It revolves around the same issue I raised in my answer to Deputy Ó Caoláin. The cornerstone of good governance is open lines of communication and open disclosure, but we also need other elements. The cornerstone of good obstetric care is the staffing level. This must be appropriate for our activity levels. We must also have an appropriate infrastructure. One cannot put 40 deliveries per day through nine delivery rooms. It would not work and would be too much strain on staff. Staffing, facilities and infrastructure have been stretched significantly in recent years. Funding of the service is also important. Maternity services have been underfunded compared with the level of activity in the system. These four elements will be important in the development of our service.

As to where we should be look for best practice, there are good models across the world, for example, in elements of what Australia and Canada do. However, one cannot just transplant a system from one health service into another because one is not comparing like with like or starting with a blank canvas. One should take the good elements and consider what is available. Plenty of evidence of best practice has been published. We have discussed reports, for example, Hanly in 2003, KPMG in 2008 and the recent report on manpower. They are all saying exactly the same thing, namely, that we do not have enough midwives and doctors in the systems. We must rectify that situation.

This brings me to Senator Colm Burke's question on how to ensure that we bring more people back to the system. We must be competitive in the package that we offer. It is not just about salary, but services, operating theatre lists and the ability to practise what people have learned abroad. Deputy Catherine Byrne asked about the culture of people travelling abroad to train. I did that, as do the majority of people. One qualifies as a doctor, decides what one wants to do, does a year or two in Ireland and learns the basics before going away, subspecialising and becoming skilled in a particular area. Previously, people used to want to return. Nowadays, that is not the case. We have well-qualified doctors. Some of the best in the world come from Ireland. Unfortunately, they are not returning anymore. This boils down to the package that we can offer, including facilities, infrastructure, staffing and funding levels and the possibility of performing the sort of world-class research that we are capable of but which we cannot do currently because we are not bringing people back to do it.

The answer to all of these questions is that, when bad things happen, be open about them. There must be open lines of communication, open disclosure, bereavement teams and pathology. A multidisciplinary package is required to answer questions quickly, openly and honestly. The same applies in respect of the quality of the service. It all boils down to facilities, infrastructure, staffing and funding.

As to the figure of 4,000 to 5,000 births annually per delivery unit, I am not suggesting that units that deliver 1,500 or 2,000 women should close. Rather, if one wants a delivery unit that can provide a medical model of care - I do not like talking about medical models - including the full range of anaesthesia, perinatal pathology, 20-week anatomy scans and foetal medicine and newborn babies looked after by neonatalogists, not paediatricians, one needs a critical mass of approximately 4,000 or 5,000 deliveries in order to ensure that those people have enough work to maintain their skills. One will not get value for money from a smaller unit because, although teams will be on call and available, they will not be doing much with their time. If a unit with 1,000 deliveries has a full team of obstetric anaesthetists, they will not be doing a great deal for much of the time. I am not sure whether I have answered the Deputy's question.

I am not sure either.

Dr. Sam Coulter-Smith

What I am saying is that it-----

What is Dr. Coulter-Smith proposing?

Dr. Sam Coulter-Smith

It boils down to patient-centred care. One provides-----

Is Dr. Coulter-Smith saying that 4,000 to 5,000 deliveries could be handled by units liaising with or forming parts of other units?

Dr. Sam Coulter-Smith

The hospital groups give us an opportunity to use a hub-and-spoke model for the services we provide. For example, there is a new initiative between the Rotunda, Drogheda and Cavan in respect of perinatal pathology services. Cavan would not have sufficient numbers to justify a perinatal pathologist's appointment there. However, if one appointed a perinatal pathologist to the Rotunda to take responsibility for the services to Cavan, he or she could work alongside perinatal pathologists in the Rotunda, keep up to date on current practice and provide the services that were required in Cavan and Drogheda without being there. It is a question of dealing with the subspecialties in a hub-and-spoke model.

Dr. Coulter-Smith accepts that some of the services that his document correctly suggests are necessary can be provided from a region or centre.

Dr. Sam Coulter-Smith

Yes.

Dr. Sharon Sheehan

I thank the Deputy for these questions and will start with them. The Deputy asked whether 19 maternity units constituted a viable option and where else we might examine. Thankfully, the maternity strategy is not a review of maternity services. We have so many reviews that another would be a waste. The strategy considers the future of maternity services and how to plan those. The chair of that group, Ms Sylda Langford, is keen on there being implementation. I welcome her strong views on its necessity.

We must be careful when considering our maternity units and our country that we do not end up with a coastal maternity service wherein the larger units in Dublin, Cork and Galway are the providers of all maternity care, with anyone living in the centre of the country not being catered for. I caution against a coastal remit in respect of maternity services.

Certainly at the strategy meetings-----

When the strategy is published, I am sure it will act as a counterfoil to what Dr. Sheehan is suggesting could happen.

Dr. Sharon Sheehan

Do I think the strategy is going to suggest that there will only be five or six-----

No, that it will recommend the opposite to what Dr. Sheehan is saying could happen in terms of the coastal effect.

Dr. Sharon Sheehan

I would suggest it will not offer a coastal effect.

That is what I am saying.

Dr. Sharon Sheehan

Yes. We need to be very careful because there is a fear among larger units as well that they will suddenly not be able to cope with having 12,000 to 13,000 deliveries in their units and the smaller units are obviously fearful of closure. It is not for me to say whether units should close as that is way beyond my level of expertise. We need to look at providing a nationwide service of maternity care and how that can best be provided across hospital groups and centres. The hub and spoke model, to which Dr. Sam Coulter-Smith, referred is very important.

As part of the strategy, we have had a number of invited speakers in to speak to the steering group. We have invited in Paul Fogarty, who is involved in the Northern Ireland maternity services strategy, and Polly Ferguson, who is involved in the Wales strategy. Wales would have similar demographics to ourselves in terms of the length of time it would take for some patients to travel to a maternity unit. Many of the women who come to our hospital, the Coombe, live in a catchment area where it would take anywhere between an hour to two hours to get to our hospital. When we consider Cork and Kerry, it could potentially take four and half hours for a woman to travel to the nearest maternity unit. Those women must be provided for. We must be able to offer a safe service to every woman in the country. As Dr. Sam Coulter-Smith said, we need to decide what levels of care can be provided, in which hospitals and at which point is it more appropriate to transfer a particular woman and-or her baby to another unit that can offer a different level of care. We already do that and that works very well.

It is in the context of the community model that we are able to expand our services in terms of antenatal and postnatal care. If one were to go into any of the Dublin hospitals, one would see that the antenatal clinics are burgeoning with patients who do not need to be there. That care can, and should, be provided in maternity and community settings. We offer community midwifery care, as does the Rotunda Hospital and Holles Street hospital. It is important for us to expand that. What works very well is where patients only come to the hospital to deliver their baby. We have many clinics running like that, where the women are seen and have all of their antenatal care in community. We have a clinic which runs from Naas hospital. It does not have a maternity service, but we run a full antenatal clinic there. Patients are booked to that clinic, have a scan done there, have all of their antenatal care there and only attend our hospital to have their baby. We need to replicate that model across all our communities, where we only bring the patients into hospital who really need to be there. We need to stop medicalising it where it does not need to happen. That is response to the question with regard to what happens in other countries.

I would echo Dr. Sam Coulter-Smith's point that we need to look at other jurisdictions. As I said, we have looked at Northern Ireland and Wales. Australia, Canada, the Netherlands and other countries in Europe also need to be looked at. I second the point that was made, that we cannot pick up a strategy and system in place in another country and simply drop it down in Ireland and expect it to work; that will not happen. We look at the UK, as our closest neighbour, but it has a very different health service from ours. Its funding mechanism for health is entirely different from ours but its community midwifery services are extremely well developed.

I return to other points that were raised in that context. The roles of the general practitioner and the public health nurse are very important. It is very useful to have general practitioners and representatives on the national steering committee. I am not sure if everybody knows but obstetrics is not a requirement of the general practitioner training scheme. One either does obstetrics or one does another model, so not all of our general practitioners are trained in obstetrics. That is an important aspect.

I would also add that public health nurses who look after mothers when they are discharged and the babies when they go home are not employed by the hospitals but are HSE employees and midwifery is no longer a requirement to do public health nursing. It always was in the past. We always trained staff in midwifery and then they went on to become public health nurses. They are no longer required to train in midwifery and yet they are expected to look after mothers and babies when they go home to the community. We need to have an integrated structure and, as I said in my presentation, we need to have a integrated workforce planning strategy in place to match the kind of services that we expect and are able to deliver.

I will move on to Deputy Ó Caoláin's comments, although he is no longer here. He spoke about the deny and defend culture. I would like to deny that this culture exists in our hospital. Open Disclosure was launched by the HSE in conjunction with the State Claims Agency but I would argue that open disclosure exists in our hospital. One of our board members has raised concerns over the title, Open Disclosure, which implies that the disclosure we had heretofore was, in some way, potentially closed. I would echo those concerns. We have a very open culture with our patients. It is important to maintain that, to acknowledge and apologise when an adverse event has occurred and to establish, along with the patients and the staff involved, what went wrong and how we can improve the service.

Deputy Catherine Byrne and Senator Burke mentioned the effects on staff who are involved in an adverse outcome. There is emerging evidence of, and talk about, a second victim in an adverse event. The staff members are now being referred to as a second victim. An adverse event often has life-changing impacts. We are all traumatised when something goes wrong. We are traumatised by the loss for the family and share in the grief experienced by the family when something goes wrong. There is the trauma of an adverse event and then there is the trauma associated with potentially being in the coroner's court or potentially being in the legal system, which is a long-drawn out process. There is emerging evidence to suggest that there are suicide rates associated with staff who have been involved in adverse events and that they are increasing. We have a huge role to play in supporting our staff when these events occur, in addition to supporting our patients. We have advanced bereavement support in the Dublin hospitals but such support in the other hospitals leaves a lot to be desired because of a lack of resources around that.

We have a number of systems in place for our staff, certainly in our own hospital, in terms of employee assist programmes, to look after them when they are involved in such cases but such cases can go on for years. It may be ten or 15 years before a case appears in court, particularly a case involving a baby who has been born with cerebral palsy. That has hugely life-changing consequences for the family but also for the staff. Staff may never again work in medicine after an adverse event and we need to support staff. I would strongly echo what has been said in that respect.

I have addressed the questions Deputy Ó Caoláin asked about the models of care. He also asked about the moratorium and my reference to staff moving. Many of our staff had been commuting significant distances during the HSE embargo on recruitment. Following the lifting of the moratorium in the HSE hospitals and as posts opened in hospitals, such as Portlaoise, Kilkenny and in hospitals around the country, our staff who lived in those areas were able to obtain employment and moved back to those hospitals. We saw an exodus from the Dublin hospitals largely of staff moving to HSE hospitals where they could not heretofore get jobs.

The other questions put to me related to community care. As I mentioned, the main elements are in terms of antenatal and postnatal care. Who would not want to be cared for in one's community? Which one of us would not want a midwife to essentially come home with us when we go home with our baby and when we are learning to breast-feed and look after our baby? Women are given an enormous responsibility, that of being able to look after a baby, for which nobody has prepared them, and what woman would not want the midwife to visit her every day at home? We need to develop, resource, staff and fund that service.

Senator Burke raised a question regarding the 114 whole-time equivalents. I would add that they are not even 114 whole-time equivalents dedicated to obstetric care. In respect of the number to which the Senator was referring, we are all qualified as consultant obstetricians and gynaecologists. There are not 114 whole-time equivalents in pure obstetrics as the number dedicated to that care is far fewer than that. Too often when we think of maternity services, we think only of the number of births. More than 8,000 surgical operations are performed in my hospital every year and those are taken out of and resourced from that complement of obstetricians and gynaecologists.

It is far more than simply the number of births delivering that defines our services.

Reference was made to staff going away. Deputy Byrne mentioned that she has spoken to staff who are leaving because there are no positions open here. That is a real concern. Like Dr. Coulter-Smith, I trained abroad and I welcome people going abroad to train. What is unique, however, is that many of our staff who leave to train abroad have absolutely no intention of coming back to Ireland. That is new. We refer to ourselves as having a homing pigeon beacon, something inside our brains that makes us want to come home. This seems to have been switched off in the staff who are qualifying and training now. I sat amidst a group of UCD medical students last year who were embarking on their obstetrics and gynaecology programme. I asked for a show of hands for how many saw themselves with careers in Ireland eventually. Less than half of the class raised their hands. That is unique. In my class in UCD, everyone wanted to come back here. We all aspired to work in Ireland and put back into the system what the system had given us in our training. We are now training to export and we need to ask ourselves why that is. Why are our jobs and hospitals unattractive? They are not. We are delivering excellence in outcomes for mothers and babies, but we need to ensure that the resources and funding are put in place to recognise that and develop it. We must avoid being short-sighted or knee-jerk in our reactions by quickly changing one problem but ignoring what may be a far greater problem in the room.

Senator Henry discussed picking up rare diseases in pregnancy. Her case epitomised the care needed in maternity care. As a young healthy woman she developed a potentially life-threatening complication although she would probably have been considered a low risk. The low-risk mother can become high-risk at any point in her pregnancy and we need to be able to cater for the needs of all our patients. We need to recognise that simply because a woman is low-risk at the start of her pregnancy does not mean she will stay in that category throughout. This is why I urge collaboration across midwifery and obstetric care as well as the other medical specialists who we rely on heavily when patients develop complications. We need to be able to seamlessly transition our patients to the appropriate care when and as they need it. It should be possible for a woman to book in a hospital that may not have certain expertise but where the training is in place to recognise when she develops a problem. This should facilitate her being moved to the appropriate centre of excellence to ensure she receives all the care she needs. I urge us not to get lost in the debates of territorialism of maternity services, the idea that a woman must remain low-risk or high-risk or that she must be in midwifery care or consultant-led care. Let us forget about that. Let us move as the needs dictate. We must remember that we have two patients: the mother and the baby. A low-risk mother may carry a high-risk baby. Conversely, a high-risk mother may carry a low-risk baby. That is the key and that is why obstetrics is referred to as an art. We need to work seamlessly across health care professionals to deliver what patients need, not what I, as a consultant obstetrician, need or what a midwife needs. We should let our care be truly patient centred.

I want to raise the coroner situation. I know there is a good relationship in Dublin but in other parts of the country there have been unreasonable delays in inquests. My understanding is that there is no statutory requirement on a coroner to hold an inquest within a set period. Should we take up the issue at this stage? Once all the necessary documentation has been filed with the coroner, we should ensure that the coroner deals with the matter within a specific period. As I understand it, that is not the position at the moment.

In fairness to Dr. Coulter-Smith, he made the comment that there might be a variety of reasons. The key point he made was that there was no closure and it was ongoing trauma. Anyway, I think your suggestion is one we should pursue.

In fairness, it is something we should take up with the Minister for Justice and Equality because it comes under that Department. There is no statutory requirement.

That is a very good suggestion.

Dr. Sharon Sheehan

I wish to add a comment. We have a really good relationship with the Dublin city Coroner, Dr. Brian Farrell. I have spoken to him about these challenges. We know it is extremely difficult for parents to wait for up to two years to know why their baby died. Dr. Farrell has emphasised the extraordinary workload on the Dublin city coroner's office. I suspect that applies to all coroners. I gather the delay in obtaining reports across specialties and individuals has resulted in the delays. Anyway, they are unacceptable. Certainly, I would not deign to speak on behalf of Dr. Farrell but in many conversations I have had with him on the matter, I have ascertained that there are major delays in obtaining reports. The volume of work makes it really difficult to hold those inquests or, if there is not going to be an inquest, there are often problems issuing the final report on the cause of death earlier. This is a major challenge.

Dr. Sam Coulter-Smith

I wish to echo what Dr. Sheehan has said. Dr. Farrell does an incredible job. He is very sensitive to the needs of families and does his best to accommodate them. However, there is clearly serious pressure in terms of the workload and this impacts negatively on what is already a very negative experience for families. It prolongs the process. Anything that can be done to help smooth that path would be very welcome.

I want to clarify that I am referring to cases where the coroner has all the documentation and there is still a delay. That is the issue I am raising.

I thank Dr. Coulter-Smith and Dr. Sheehan for their presentations and the questions and answer session. We will discuss some of these issues in private session next week.