Seanad Éireann debate -
Thursday, 20 Oct 2005

Vol. 181 No. 9

Acute Hospital Services: Statements.

Minister of State at the Department of Health and Children (Mr. S. Power)

At the outset, I would like to take this opportunity to offer my sincere sympathies and those of the Tánaiste to the family of the late Mr. Patrick Walsh, who died tragically at Monaghan General Hospital on Friday, 14 October 2005. Like everyone in this House, I was shocked and saddened to learn of Mr. Walsh's death. No words from anyone in either House will be of any great comfort to the Walsh family as they mourn their relative but the onus is on us to have a full inquiry into his death. There will be no cover up, the facts will disclosed and we will ensure there is no repetition of what happened to Mr. Walsh.

The House will be aware that the Health Service Executive has commissioned Mr. Declan Carey, a consultant surgeon at Belfast City Hospital and an honorary senior lecturer at Queen's University Belfast, to carry out an independent and external review of these circumstances. The review will be completed and a report issued within a timeframe of eight weeks. I hope the review succeeds in answering all the questions which have arisen following Mr. Walsh's untimely passing.

There are clearly many questions to be answered regarding the care provided to Mr. Walsh. Everyone wants answers regarding this tragedy, the political system, the Health Service Executive and the general public. Most important, we need to seek answers on behalf of Mr. Walsh's family whose distress is uppermost in our minds at this time.

It was particularly disturbing to learn, even in advance of the review, that beds were in fact available in the north-eastern region both at Cavan General Hospital and at Our Lady of Lourdes Hospital, Drogheda, to treat Mr. Walsh in the event that he required to be transferred from Monaghan General Hospital last Thursday night or Friday morning. It is now for Mr. Carey to establish all of the circumstances surrounding Mr. Walsh's death and in undertaking this task, I trust he will receive the full co-operation of everyone involved.

There has been much debate in both Houses in recent years about the configuration of medical and surgical services in the north east. Members will have taken particular note of the views expressed yesterday by Professor Brendan Drumm regarding the provision of acute medical and surgical services in the north east, having regard to best international practice. The north-eastern region operates five acute hospitals serving a catchment population of some 350,000 people. The policy basis for the provision and development of acute hospital services in the north east has been developed in recent years on foot of various studies, including a health strategy for the people of the north east and proposed development of specialist services 2001-06. This policy networks the five hospital sites in the region into two hospital groups — Cavan-Monaghan and Louth-Meath, which covers Drogheda, Dundalk and Navan — with clearly defined roles for each group and hospital.

The debate in recent days has centred on the provision of surgical services across the Cavan-Monaghan hospital group. The policy approach to the issue was set out in the 2004 report of a steering group established by the former North Eastern Health Board. This group was representative of all the key professional stakeholders and included consultant representation from both hospital sites in the disciplines of surgery, medicine and radiology. Members of the group unanimously approved the recommendations of the steering group. The executive board of the former North Eastern Health Board accepted the steering group's recommendations in late 2004.

The steering group recommended in its report that major and emergency surgery should be carried out in Cavan General Hospital and that Monaghan General Hospital should provide selective elective surgery. In making the recommendation, the group took account of expert advice received from the Royal College of Surgeons in Ireland. In accordance with the recommendations of the steering group and the expert advice from the Royal College of Surgeons in Ireland, a full surgical team based in Cavan will provide services at Monaghan General Hospital in the form of selective elective surgery on a Monday to Friday basis.

The Health Service Executive has also recently appointed a non-practising lead consultant surgeon at the Cavan-Monaghan department of surgery whose remit is to oversee an implementation plan arising from the advice of the Royal College of Surgeons in Ireland on the future configuration of surgical services in Cavan and Monaghan. With regard to medical services and in accordance with the steering group's recommendations, Monaghan General Hospital returned to 24-hour, seven-day medical cover in January 2005. A third consultant physician has been in post since November 2004 and five new anaesthetic non-consultant hospital doctors have been recruited to facilitate the return of the hospital to medical on-call.

Surgical services within the Louth-Meath hospital group were reorganised in 2004 to create a joint department of surgery across both the Drogheda and Dundalk hospital sites. Under these arrangements, all consultant surgeons provide services across both sites. A Drogheda-based consultant surgeon, with 24-hour, on-call non-consultant hospital doctor support, provides emergency on-call cover for the joint department. I understand that, as in Cavan-Monaghan, the service arrangements for the joint surgical department at Drogheda and Dundalk are supported by the Royal College of Surgeons in Ireland. The reorganisation of surgical services in both groups is designed, inter alia, to facilitate a more appropriate training system in that junior doctors will rotate between the hospitals during their employment, thus ensuring exposure to many different clinical experiences.

The arrangements for the north-eastern region that are being put in place by the Health Service Executive were developed in order to enhance the overall level of medical and surgical services. However, no matter how much careful preparation is put into formulating arrangements such as I have described, we must also work collectively to ensure their delivery and avoid a repeat of the tragedy which occurred at Monaghan.

Mr. B. Hayes

I extend my sympathy and that of my party and colleagues in the House to the Walsh family following the tragedy which took place in Monaghan General Hospital last week. It is very important that this matter is debated in the House, which is why I sought a debate on the Order of Business yesterday. I am glad that the Minister for State is with us today and thank him for putting his remarks on the record of the House.

The Minister of State has not given us additional information but it is important that colleagues at least raise the issue, put questions and have the matter recorded. There is a very dangerous assumption abroad that, with the advent of the brave new world of the Health Service Executive, politicians cannot comment on issues such as these. This assumption must be knocked on the head. Politicians decide the broad parameters of policy through the Department of Health and Children. Politicians also fund the Department of Health and Children and the various State agencies responsible for delivering policy. It is absolutely right and appropriate that politicians debate issues such as this when tragedies occur and seek accountability from the Government as to the exact scale and nature of the operations of such a crucial health service. I make no apologies for ensuring such a debate takes place in this House.

I heard the comments made by Professor Drumm yesterday morning. I agree largely with him that we cannot have a health policy directed by the local considerations of one group of politicians over another group of politicians. Let us also be clear that in the past there have been gigantic political manoeuvrings within the medical world, irrespective of party politics, where medics have sought to look after their own geographical area against other areas and one hospital pitted against another. One has to look at the decisions that come from An Bord Altranais at times in terms of trying to ascertain the rationale for them. Ultimately, the only people who are accountable are those who are elected to this or the other House. Consequently, we should make no apologies in asserting the right and the primacy of the Oireachtas in terms of getting answers to these questions.

From my discussions with people in the area and my colleagues in the other House, the people of the north eastern region are not looking for five acute hospitals that will deliver every surgical procedure that will look after every circumstance in the Irish medical health care system. What they are seeking is a guarantee that what happened to Mr. Walsh, and the tragic events that will always affect his family, will not happen again. That is the reason we have to put on the record a number of basic questions that must be answered. While I fully accept the need for the inquiry, which will be of eight weeks duration, these questions can be readily answered because the information is to hand.

The issue is whether there is a directive in place which states that a person who presents with a life threatening medical problem in this hospital cannot be dealt with. The Taoiseach told the Dáil yesterday that no such direction came from him, the Tánaiste or anyone else. It is clear from Dr. Duffy's comments on national radio yesterday and the experience on the ground that there is a clear directive that life threatening cases cannot be dealt with in this hospital. That is bizarre. It is bizarre that the HSE or any other group would dictate such a policy. Will the Minister of State confirm a matter to which Dr. Duffy alluded yesterday, namely, if it is the case that in January 2005 in Monaghan General Hospital where an urgent case developed requiring immediate surgical intervention to protect a person who needed emergency surgery, the doctor who carried out the surgery was later chastised and criticised by hospital management for doing so? Dr. Duffy and others have referred to this but the Government has not commented. If that is the case it is astonishing that a senior surgeon would be openly criticised by hospital management for a medical intervention that saved a person's life. It gets worse.

Another issue on which I would like the Minister of State to comment is the two further cases since Mr. Walsh's untimely death last week where patients were shunted around the region at the last minute because they were told in Monaghan General Hospital that it could not deal with the circumstances of their case. Is that a fact or is it not?

Why did it take four days for the Department of Health and Children to confirm that beds were available in Cavan and Drogheda hospitals? We know from this morning's newspapers that a bed was available in Beaumont Hospital. The manager in Beaumont Hospital stated categorically to the authorities in Monaghan General Hospital, as I understand it, that the acute bed was available and it was encouraged to come back and state whether this facility would be needed in respect of Mr. Walsh. Why did it take four days for that information to be revealed? That is an open and shut case that should have been brought to the attention of the Minister and the House much earlier.

It is a disgrace that skilled surgeons and medics had to look on as a man lost his life last Friday and could not intervene because of some bureaucratic ruling which the Taoiseach and Tánaiste say does not exist, but clearly does exist. That is an issue on which clarity is needed.

We speak regularly of joined-up Government. If ever there was an example of how the medical services are getting it wrong in their treatment of the north-eastern region — an issue my other colleagues are more adept at discussing in that they live there — a region of 350,000 people, it is surely this. Why are we getting it so wrong? The Government has known about this problem. Last year in the other House my colleagues tabled a detailed motion on the problems in the North Eastern Health Board region but no action was taken to knock heads together to get a solution and work on a protocol to which everyone could agree.

If we are serious about delivering a world class service for everyone in the country, not just those who live in big cities, such as myself and others, there has got to be a strong political involvement that signs up to whatever arrangements are agreed. Clearly, the tragedy of Mr. Walsh and the ongoing problem in Monaghan General Hospital is an issue that has to be resolved sooner rather than later. I wish the investigator every success. The three issues I have raised can be confirmed if the Minister of State can reply to the debate by way of a short statement.

Acting Chairman

This debate will conclude at 2.30 p.m. and the Minister of State will have five minutes to reply.

Mr. O’Brien

I welcome the Minister of State at the Department of Health and Children, Deputy Seán Power, to the House to discuss this sad event. I thank the Leader of the House, the Tánaiste and the Minister of State for arranging to have this debate, which was called for yesterday, at such short notice. I express my sincere sympathy to Mr. Walsh's family and his extended family. His family has suffered much grief since Mr. Walsh passed away. We know at this stage that this man's life could have been saved if the restrictions which did not allow the medical profession to perform the operation on him had not been in place at Monaghan General Hospital. That is bad enough for the family members in these tragic circumstances but the revelation that beds were available must add to the family's grief at this sad time.

I welcome the announcement by the Tánaiste that an inquiry will take place into the incident and I hope answers can be given to the Walsh family. I was instrumental in organising a meeting with the Taoiseach and the hospital alliance group last Friday night to hear their concerns. It was stressed to the Taoiseach that surgical procedures should be dealt with as people present to the hospital. I hope this can be agreed without delay.

The problems with Monaghan General Hospital stem from it being taken off call for surgical cases. Had the hospital been on call for surgical cases, the personnel would have been available to treat Pat Joe Walsh when he presented. Certainly his death would not have taken place when it did. Unfortunately the hospital has had ongoing problems for some considerable time. It is the view of the people of Monaghan that they should be entitled to acute surgical services when they need it. Unfortunately this is not the case at present.

In addition to the death of Pat Joe Walsh, numerous other unfortunate incidents have occurred in the past two or three years. Nothing has been done and we need something to be done immediately. This cannot continue. Following the last death and the previous one we made the same case that Monaghan General Hospital should be on call for full medical and surgical services for the people of County Monaghan. They are entitled to nothing less. Where the necessary skills are not available an arrangement must be reached with the other hospitals in the region and, if necessary, outside the region to ensure no patient is denied a bed when needed. Now that the Health Service Executive is in place I hope it will ensure the necessary arrangements and services are put in place in Monaghan General Hospital to cater for the needs of the people of Monaghan.

I again sympathise with the Walsh family. This was a tragic and untimely death in the circumstances. Unfortunately nothing we say in this House will bring back the life of Pat Joe Walsh. At this late stage I beg the Minister of State to ensure that the services that Monaghan General Hospital requires are provided for the people of Monaghan.

Mr. Norris

I agree with Senator O'Brien in complimenting the House and its political staff on getting this debate scheduled so quickly. It does a public service that this matter be so ventilated. It is very useful and I am glad we are having the debate. I wonder whether the Tánaiste, Deputy Harney, now regrets so courageously taking on the poisoned chalice of the Health and Children Ministry. It certainly was a courageous decision and confronting this task provides many headaches. She is right in saying that the whole system of health delivery needs to be reviewed.

The specific tragic case of Mr. Walsh is an appalling event. One would first of all have to send one's sympathy to his relatives. First they had the incidence of his illness and then they had to stand impotently by while he was locked into a kind of lunatic bureaucracy. I understand Mr. Walsh was already known to suffer from a peptic ulcer, which creates certain indications. I would have thought he should have been put into intensive care immediately. This kind of bleeding is amenable to fairly simple treatment through endoscopy whereby a tube is inserted and the bleeding is cauterised, which is successful in 80% of cases. Without this procedure it is almost always fatal. It is not a major, sophisticated, complicated or difficult operation to undertake. It astonishes me that people stood idly by while this man apparently bled to death.

We need to get all the facts — I understand a report is due and we must await judgment. It would be quite wrong to judge specific individuals or name anybody at this point. While I do not always agree with Senator Mansergh, he was very wise in what he said on the Order of Business when he brought to mind the simple parable of the good samaritan and asked whether in these kinds of conditions someone who found a man bleeding to death on the side of the road would, as they used to say about the American health service, first feel his wallet to see if it was still beating and then just look around and decide if there was an inhibition here to prevent him being helped for various reasons. Senator Brian Hayes asked a very pertinent question in wondering where this inhibition came from. It seems clear it did not come from a political source. It may have come from within the hospital. It is appalling and astonishing that a surgeon who intervened courageously to save life on a previous occasion was reprimanded and chastised. This is not a good indicator for the health service and these matters need to be clarified.

We also need to consider the insurance situation. We need to ensure that not only are those medical staff, who courageously intervene, covered and given political protection by being supported when they take such action in the line of their work, but also that they are not subject of the threat of enormous financial loss. For example, a surgeon might intervene in the case of a person who was already beyond saving. Then, as happens frequently in other jurisdictions, the well-intentioned surgeon is slapped on the wrists and taken to court. A few years ago in America a woman collapsed beside a swimming pool with a ruptured appendix. A doctor operated with an ordinary domestic knife and saved her life. Her grateful response was to sue him and receive $750,000. We must protect medical personnel against this kind of risk.

We should not use these matters to excoriate particular politicians, to hold them directly or personally responsible, or to score political points. We should have in mind the general welfare of the community. I welcome that the Taoiseach in the other House made it clear he would stand against these kinds of personal accusations by saying: "I will not accept that there should be political accountability every time a person dies anywhere in our health service." He is right and we, as politicians, on all sides should support him in this matter.

I remind the House that we are perishable goods. Death is inevitable. One hopes to accomplish it with the minimum of trauma or suffering. I am not referring to the situation of Mr. Walsh which is a separate business. Sometimes the impression is given in this country that people believe they are entitled to live forever; that if they get a cold the local TD is responsible; if they have an operation the Minister is responsible; and, if they die the Government should fall. This is not realistic. Our health service is not as bad as we make out. There are difficulties in delivery, there is appalling bureaucracy, there are too many managers and the Hanly report should be implemented.

On this I disagree completely with Senator Leyden who spoke from the Government side of the House and who attacked Professor Drumm. I say, thank God for Professor Drumm and his clarity, forthrightness, decency and honesty in addressing a situation. We should leave it to him and not attempt to interfere politically in the interests of our own little backyard. I am sickened by what I see on all sides of this House. Every party is involved. Every party wants to save its own hospitals but what they mean is they want to save their own seats. This is not about a hospital but is a popular voting issue that calls for people of courage. If the political leadership is not forthcoming from the political parties, then I urge Members not to attack people like Professor Drumm who know what they are talking about and have the experience. The Government should not waste its time appointing somebody with expertise if it will not listen to it. I agree it is a situation which needs discussion. Professor Drumm is perfectly correct in his view that one cannot have five hospitals with a huge range of expertise and duplication within a small area.

I remember the situation 30 years ago when the Minister for Education was giving lessons about the proposed university merger involving Trinity College. The argument was that duplication was not desirable and in some ways that was valid; it is certainly valid in terms of the delivery of hospital services. However it must be ensured that people can be brought rapidly from one hospital to another and that beds are available. There should be a computerised system to show where beds are available. There should be correct ambulance transport and properly trained personnel to ensure people do not die in ambulances. I urge the Government Members not to go against Professor Drumm and his courageous involvement and intervention in this matter.

There is clearly something wrong in the hospital system within this localised area. It is astonishing that this man was denied treatment in a hospital; it would be a different matter if he could not get to the hospital. Senator Brian Hayes referred to another situation where a person was denied admission to a local hospital. The staff of the referring hospital decided they could not bear the repetition of having to stand by and watch a patient bleed to death so they took it upon themselves to telephone the senior administrator of Cavan General Hospital who was in bed in the early hours of the morning. He instructed the staff to admit this man. Why did that have to happen? What is the ethos and where is the notion of the hippocratic oath?

I do not know if the oath was ever administered to doctors but it is something in the popular imagination, like the 1916 declaration about cherishing all the children of the nation equally. The public has the idea in its head that a medically qualified and trained doctor will do everything possible to keep people alive. It could be that this oath no longer exists but the ethos should. We should feel confident that if we are in distress or at death's door, at least a proper, civilised effort will be made to spare our lives.

We are all perishable goods, our time is short and we might as well get used to it. The best we can hope for is reasonable treatment and an easy passage out of this world because that day will come. We must be realistic. Our demands on the health service are increasing every day to totally unrealistic dimensions, particularly in the view of people of my generation. I remember when people would die of an inward pain and nobody quite knew what it was. People accepted the realities of life.

Realistic plans must be implemented. The Hanly report will improve the situation. If Professor Drumm states a modified form of the Hanly report is required then he should not be attacked politically but should be congratulated on telling people the truth. It may be difficult for politicians in their own constituencies to tell the truth but Professor Drumm should not be attacked for doing so.

Mr. Wilson

I welcome the Minister of State, Deputy Seán Power and his officials to the House and thank them for attending at short notice. Along with Senator Brian Hayes and my colleague, Senator O'Brien, I raised this matter on the Order of Business yesterday and I thank the Minister of State for coming to the House to hear the contributions today.

I regret that time is limited but I am pleased to have time to comment on the ongoing difficulties in respect of Monaghan General Hospital. I offer my sincere sympathies to the family of the late Mr. Patrick Walsh. No words of mine or of anyone else will bring that poor man back to life.

The Tánaiste has employed the services of an eminent consultant surgeon from Northern Ireland to investigate this sad saga. The Minister of State has clearly stated to the House that answers will be given and will be made public, that there will be no cover-up and no opportunity for anyone to pass the buck. I welcome these initiatives.

As I stated on the Order of Business yesterday, none of us is a medical expert. I was not present in the hospital when this sad event occurred nor was I speaking to anybody who was present. I regret the investigation by the eminent consultant will take eight weeks to conclude but I am willing to wait for eight weeks in the knowledge that action will be taken on foot of his conclusions.

I want answers to questions such as the reason it was necessary to move the late Mr. Walsh from the hospital in Drogheda so soon after his hip operation. Why was his ailment not diagnosed and, when diagnosed, why was the fact that beds were available in Cavan General Hospital, in Drogheda and in Beaumont Hospital not known? Both the general public and I want answers to those questions.

On a number of occasions in this House, Senator O'Brien and I have raised the matter of the need to expand the surgical services at Monaghan General Hospital. The people serviced by Cavan General Hospital and Monaghan General Hospital deserve to have adequate and efficient facilities provided for them.

Both hospitals have been under sustained pressure in the past number of years. I take this opportunity to pay tribute to the staff in both hospitals who work under very difficult circumstances. I welcome the recent announcement by my colleague, the Minister of State, Deputy Brendan Smith, of 25 additional beds to be provided in Cavan General Hospital. I welcome the announcement that an additional operating theatre and additional beds will be provided in Monaghan General Hospital along with the refurbishment of some wards.

However, Senator O'Brien and I and the people of Cavan and Monaghan want a clear statement on the future of Monaghan General Hospital. I do not expect the Minister of State to provide such a statement today at such short notice, but we will be seeking a general debate in the near future on hospital services in the north eastern region, particularly in Cavan and Monaghan.

Senator O'Brien was instrumental in organising a meeting last Friday between the Monaghan Hospital Alliance and the Taoiseach. I understand from some representatives of the alliance that they were happy with the meeting. It is tragic that before the Taoiseach left Monaghan Mr. Patrick Joseph Walsh passed away.

I am willing to wait eight weeks before I start passing judgment or making remarks. However, after the eight week period, I want answers. I express my sincere sympathy to the family of the late Mr. Walsh. None of us can bring him back but hopefully his death will not be in vain and we will be able to get this situation sorted out. I also want to thank my colleagues in the House for their balanced comments on this sad episode.

Mr. Ryan

I hate occasions such as this. These are not circumstances in which it is appropriate to beat the Government over the head. A man died and there is a need for a certain amount of restraint. I know that if anyone in Government could wave a magic wand, this type of incident would not happen. Therefore, if I use strong language, it is not because I believe people care less than I do about this situation. What troubles me every time something like this happens is the fact that there is no sign of a learning process taking place. There is no sign that we are advancing because we continue to have tragedies like this one in areas of public service provision.

As an engineering student I did a small amount of management studies as part of my course. I was taught that the function of management is to plan, organise, staff and control. That is standard business studies teaching. It is extraordinary that we do not know what, precisely, were the rules under which Monaghan General Hospital was working. I do not want to point the finger. There has been a tendency in some quarters to point the finger at the people who were working in the hospital, but they are not the managers of the health service in the north eastern region. They are the people who work on the ground and it is not their responsibility to plan for the service. It is also not their responsibility to organise and staff the service, nor to control how the service operates. That is the function of management.

The fundamental flaw in our health service is the absence of a clear and transparent line of management authority. Ideally Senator Wilson or Senator O'Brien, for example, should be able to say that the person who knows precisely what is supposed to happen is X. This is not the case in reality. Let us suppose there was a fatal accident in a pharmaceutical plant in Cork and the Health and Safety Authority arrived on the scene to be told by the management that it was conducting an independent inquiry and would be able to tell the authority in eight weeks time precisely why a person was killed. In such a scenario, the HSA would have the management in court the following day. I do not understand why we cannot find out the precise operating instructions for the staff of Monaghan General Hospital who are there after 5 p.m.

People are now talking about exceptions, emergencies and so forth but we do not know how the hospital staff operate. Nor do we know the precise instructions given to the staff in Cavan General Hospital. The services are either being run on an ad hoc basis or they are being managed. Many senior public officials have told me that the gap in salaries between the top and bottom levels in the public service has expanded dramatically in the last 20 years because of the major increase in responsibility taken on by managers.

However, when we have a problem like this one, management goes missing — although in this instance, Professor Drumm was an honourable exception to that norm. In this instance, the managers have gone missing because there is an eight week inquiry taking place and, therefore, they cannot comment on the matter. Why should it take eight weeks to find out why a fundamental systems failure happened? If one wants to include a plan to ensure that such a failure never happens again, then perhaps eight weeks is a reasonable length of time. We want to know on whose authority it was decided that Mr. Walsh could not be transferred to another hospital. Whose rules were in operation, what precisely did those rules say and are they written down? If so, they should be published now. If there are unwritten rules, let us hear them now.

In eight weeks time we will receive a report which, I am willing to bet, will identify a systems failure. I have heard of so many systems failures in Ireland in recent times. Another part of the report will contain a statement from the HSE asserting that the problems are all in the past and that it has devised new procedures to guarantee that such a systems failure will never happen again. Another likely finding in the report is that no senior member of management in the HSE is accountable or culpable in this case. Perhaps no one is culpable and such things can happen. However, if a gap in planning for service provision is identified, then it follows that somebody who was paid to manage the service allowed that gap to open up. As has happened in similar situations, it will probably be the nurses, doctors or some junior official who will be blamed for not doing what they were supposed to do or for exceeding their authority. It will emerge that such people were supposed to know what to do but that the service provision was not planned properly.

If we are to have a proper health service in this country we must get to a point where those who are called managers actually manage the service, where they are not merely administrators. Managers should not be people who simply transmit orders from above to those below or transmit information from below to those above them. Managers must take responsibility and if they do not, they should not be in managerial roles. That is the fundamental point and we do not need an eminent medical professional from Belfast to examine our management system. In fact, he is possibly not the best person to examine the management system, but it is with that system that the fundamental problem appears to lie.

If one decides that a particular hospital cannot provide certain services between 5 p.m. and 9 a.m., then one is duty bound to plan for what happens if an emergency arises during those hours. One must go through all the eventualities, deal with all the possibilities and have a procedure which is tested and works. It cannot always be the case that some kind of tragedy is necessary for health service management to realise there is a fault in its planning or management. It cannot be changed by tragedy, which is awful. It is a bit like saying that the safety of the chemical industry would only be examined after someone is killed. The fundamental way the best parts of our industries work is by pre-emptive planning to avoid anything going wrong.

Related to this are some of the comments of the chief executive of the HSE. I refer to it as the HSE, because I presume when he speaks, he speaks for the HSE. The presumption is that big hospitals are better, which is the basic argument of the Hanly report. The statistical evidence used in the Hanly report has been challenged and demonstrated to be dubious. First, there is not a convincing study of the statistical evidence which could convince any objective person that, in 80% of cases, a small number of big hospitals produce no improved outcomes. Second, while I do not claim to be an authority on it, what happened this week in the north-eastern region did not happen under the old regime. No matter what anyone said about the inadequacies of the service, the inadequacies of the training or the inadequacies of the cover, what happened this week did not happen under the old regime. It is, therefore, the responsibility of the advocates of the new regime to explain how their regime is better, instead of asking people to trust them because they know what they are doing.

Fundamentally, after an incident such as this, the issue for most people is trusting the HSE and believing its management is really in charge. What sort of system is it whereby a manager must be telephoned at 3 a.m. to persuade a hospital to take a patient? I admire the manager for taking responsibility and directing this be done. However, the real job of a manager is to organise matters in such a way that people will not have to telephone him to get something done that he or she believes should be done and has the authority to make happen. Managers do not need to be on the premises 24 hours a day. They should put together systems that work. One must have enormous sympathy for Mr. Walsh and his family who suffered, not just because of his death, but because of the way he died, which was awful.

For once in this country, we must identify lines of authority, lines of responsibility and lines of accountability based on real managers who are now paid managers' salaries, operating as managers and not as administrators, passing around other people's responsibilities. This is the fundamental issue that arises here and all over the health service.

Minister of State at the Department of Health and Children (Mr. S. Power)

At the outset, this is a difficult debate in which to participate. However, I thank Members for their contributions and the dignified way in which they made them.

I would like to repeat something I said earlier in regard to the report of a steering group, which was established in 2004. That group was representative of all the key professionals and stakeholders. It included consultant representations from both hospitals, including the disciplines of surgery, medicine and radiology. The steering group recommended that major and emergency surgery should be carried out in Cavan General Hospital and that Monaghan General Hospital should provide selective elective surgery. It is important to note that in making the recommendation, the group took account of the expert advice received from the Royal College of Surgeons in Ireland. I am aware that all Members who participated were not present when I said this.

Monaghan General Hospital is on medical call 24 hours a day, seven days a week, and medical emergencies can call to the hospital. Surgical emergencies must go to Cavan or Drogheda, and the Royal College of Surgeons in Ireland supported these arrangements. These decisions were not taken lightly. Much thought and consideration went into them and they were supported by the Royal College of Surgeons in Ireland.

A number of questions have been raised, not just by Members of this House, but by people throughout the country. I am sure the Walsh family, in particular, will be anxious to have answers to many of the questions asked here today. Some of them would be best left to Mr. Carey in his inquiry. Senator Hayes asked when did the Tánaiste become aware of the availability of a bed. She learned from the HSE on Tuesday that a bed was available in Cavan General Hospital on the night in question. She informed the House at the first opportunity, which was during Question Time on Tuesday afternoon.

The big question is who was in charge of Mr. Walsh's care and the responsibilities surrounding it. I have no doubt that the answer will be provided in the report. Senator Norris referred to the interview with Professor Drumm, who indicated his disquiet at what happened and his determination that the HSE should take responsibility for trying to ensure that such a tragic event would not happen again.

A number of questions were raised in regard to Mr. Walsh's medical condition and the appropriate treatment. These matters will be examined by Mr. Carey. While people would like answers soon, it has been agreed that the report will not take longer than eight weeks. I wish to make it clear that the only reason for setting up the inquiry is to uncover the full facts behind this very sad story. It is the least the family of Mr. Walsh deserve, and we will ensure it happens. Given that they live so close to the hospital, I appreciate that it is a great tragedy for my colleagues, Senator O'Brien and Senator Wilson, and for the people in the locality who are saddened at what happened. I appreciate their need to have a number of answers as soon as possible.

Senator Ryan appeared to be second guessing what may be contained in the report. If he wants to make these judgments, he should feel free to do so but, in fairness, we should wait for the report to emerge. In order to guarantee the independence of the report, we have gone outside to appoint a consultant surgeon from Belfast, Mr. Carey. I hope the full facts will emerge from the inquiry.

With regard to the terms of reference, Mr. Carey has been asked to examine all the circumstances covering the period commencing with the admission of Mr. Walsh to Our Lady of Lourdes Hospital, Drogheda, which took place on 21 September, until his sad death in Monaghan General Hospital on 14 October. The Tánaiste is as anxious as everyone else to have answers to the questions raised both inside and outside the House. I thank Members again for their contributions and the manner in which they dealt with this very difficult issue.

Acting Chairman (Mr. Leyden)

When is it proposed to sit again?

Mr. Moylan

At 2.30 p.m. on Tuesday, 25 October 2005.