Hospital Services.

Mr. Neville

I thank the Ceann Comhairle for allowing me to raise the important matter of the review into the death of Róisín Ruddle, Kilmacow, Kilfinny, Adare. I am a fellow parishioner of the Ruddle family and have known Róisín's mother and father, grandfather and great-grandfather, who have been highly respected members of our community. I thank the Ruddle family for their co-operation with the review into the sad case of the death of their daughter, Róisín, and sympathise with Gerard and Helen. I commend the regional health authority, its staff and the staff of Our Lady's Hospital.

On 27 March 2003 Róisín Ruddle was placed on the elective cardiac surgery list of Our Lady's Hospital for insertion of a Glenn shunt. Her surgery was scheduled for 30 June 2003. Róisín was admitted to Our Lady's Hospital on 25 June 2003 for her pre-operative investigations and discharged home on 26 June. She was admitted on Sunday, 29 June in preparation for her planned surgery the following day. On Monday, 30 June, Róisín's operation was deferred because there was no staffed intensive care bed available for her following her surgery. Róisín and her parents left the hospital at approximately 12 noon on 30 June and returned home.

Róisín died at home in the early hours of Tuesday, 1 July. She was due to undergo the Glenn shunt procedure on 30 June. This procedure was a palliative operation which was part of a staged strategy in the management of Róisín's cardiac condition. She underwent the normal pre-operative investigations as I have stated. On 30 June her surgery was deferred because no staffed intensive care bed was available.

The autopsy indicated that Róisín's death was due to acute cardio-respiratory failure associated with the presumed development of a cardiac arrhythmis. This view was supported by the medical opinion presented in the course of the review. If the Glenn shunt procedure had gone ahead as planned on 30 June, it would most likely have improved Róisín's oxygen saturation and this may have reduced the likelihood of her condition. Nevertheless, it is the view of the panel that if Róisín's operation had gone ahead as planned on 30 June, the likelihood of her survival would have been greater.

Given the centrality of the ICU to the operation of Our Lady's Hospital as a whole, the shortage of nurses to staff the unit does not appear, according to the review, to have been seen by hospital management at the time as a prior issue warranting significant management attention. From the evidence presented, it is clear that the problems relating to the recruitment and retention of specialist nursing staff were considered matters to be addressed solely by the nursing director and her staff. Although aware of the problems, there is no evidence that hospital management or the committee of management gave any active support, other than the approval of financial resources, to helping the director of nursing with the problem of devising initiatives that were clearly needed to address the recruitment issue that is central to the report and to this highly critical area of the hospital's activities.

It is the opinion of the panel that insufficient focus was placed by Our Lady's Hospital management and the committee of management on the resolution of this issue. As a consequence, there was a lack of urgency in applying and distributing available resources for resolving the problem. The panel pointed out that despite significant efforts made by the staff, the difficulty arises regarding the area of nursing. The fundamental reason for the deferral of Róisín's surgery is clearly stated by the panel. It was due to the inability of Our Lady's Hospital to recruit or retain sufficient experienced ICU nursing staff to support the available ICU beds. Among the factors contributing to the shortage of paediatric ICU nurses was a change in the system of nurse education in the mid-1990s. It was a fundamental managerial planning issue that when such changes are considered by the Department and the Minister, a planned approach should be taken to ensure that these problems do not arise.

I will raise the issue of the development and investment in Our Lady's Hospital on a future occasion. I am amazed that despite the difficulties with recruitment, the hospital does not have a recruitment website. The panel recommends such a website.

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

The report of the panel reviewing the events surrounding the death of Róisín Ruddle was published on the Department's website earlier today. The report prepared by the former Eastern Regional Health Board in July 2003 has also been published. Copies of the report were made available to Róisín's family and to Our Lady's Hospital in recent days.

I wish first of all to express my sympathy to Róisín's parents and to her extended family. They have been through extremely difficult times in the past, and the publication of this report will no doubt recall for them all the trauma of those times. Our thoughts are with them today. While it is appropriate for the House to discuss the matter, I know that our words will probably ring hollow with Róisín's family at this time.

On behalf of the Tánaiste, I thank the review panel for completing a very thorough examination of the issues that have arisen in this case. The principal finding in the review panel's report was that if Róisín's operation had gone ahead as planned on 30 June 2003, the likelihood of her survival would have been greater and that the fundamental reason behind the deferral of Róisín's surgery was the inability of Our Lady's Hospital to recruit or retain sufficient experienced nursing staff to support the available ICU beds. The Tánaiste recently met the hospital's chief executive and the director of nursing and they assured her that key recommendations in the report have been acted upon.

For example, in September 2004 the hospital assigned full-time responsibility for the recruitment and retention of specialised paediatric nurses to its most senior assistant director of nursing. A clinical bed manager was appointed in August 2004 to ensure the efficient and effective use of beds and cots in accordance with international best practice. The hospital has already established links in relation to cardiology and cardiothoracic surgery with a number of institutions outside of the country, including Great Ormond Street Children's Hospital.

The chief executive also assured the Tánaiste that the other recommendations in the report will receive the hospital's urgent attention. The Tánaiste expects the hospital's committee of management, the hospital management and the hospital staff to ensure that the issues relating to the hospital's internal organisation are fully addressed as a matter of urgency.

The reason for the deferral of Róisín's surgery on 30 June 2003 was that there was no staffed intensive care bed available in the intensive care unit to accommodate her post-operatively.

The intensive care unit at Our Lady's Hospital has a physical capacity of 21 fully-equipped beds, divided into two units, but has never been in a position to open all the 21 beds due to the lack of specialised nursing staff. In June 2003, the unit as a whole was staffed for between 14 and 16 beds, depending on the casemix between intensive care and high dependency patients. Patients requiring intensive care are nursed on the basis of one nurse per patient; patients requiring high dependency care are nursed on the basis of one nurse per two patients.

The review panel's report notes that, despite significant efforts made by Our Lady's Hospital in more recent times, the hospital is still not in a position to staff its full complement of ICU beds. The review panel's report points out that there is an international shortage of paediatric ICU nurses. In recent times, Our Lady's Hospital has, with the support of the Health Service Executive and my Department, embarked on a comprehensive strategy to recruit and retain nurses for its ICU, including overseas recruitment campaigns in Bahrain, the Philippines and Poland as well as the United Kingdom. The hospital also targets post-registration paediatric nursing students to encourage them to work in ICU.

While the hospital has had some success in recruiting nurses into its ICU, this recruitment has been offset by many of the nurses leaving the unit for various reasons. Many of the nurses working in the ICU are from overseas and some choose to return home or to work in other countries. Others leave on promotion, while others find that the stress of working in such intensive conditions takes its toll.

The hospital has taken many initiatives in an attempt to retain staff, including the introduction of family-friendly work policies and a self-rostering system for its ICU nursing staff which allows the nurse to choose his or her own working hours. The hospital also offers extensive educational opportunities for nurses and provides free accommodation to all non-national nurses for the first eight weeks of their adaptation period.

Among the factors contributing to the shortage of paediatric ICU nurses in this country was a change in the system of nurse education in the mid-1990s. Since 1996, the only route to becoming a children's nurse is to pursue a post-registration higher diploma programme over 18 months. It currently takes four years training to obtain registration as a general nurse, which means it takes a minimum of 5.5 years to qualify as a children's nurse. If the nurse then wishes to qualify as a specialist paediatric ICU nurse, he or she must first obtain a minimum of six months work experience in paediatric ICU and then complete a further higher diploma in paediatric critical care over one year full time or two years part time. It currently, therefore, takes a minimum of seven years to become a fully-trained paediatric ICU nurse. In my opinion, this is too long.

One of the review panel report's recommendations is that the overall training period required to become a fully-qualified children's ICU nurse be re-examined. The expert group on midwifery and children's nursing education has recently reported to the Tánaiste. One of its recommendations, the introduction of a direct entry undergraduate programme for combined children's-general nursing, lasting 4.5 years, must be implemented. We also need to reduce the length of the existing post-registration programme for qualification as a children's nurse. These measures will reduce the time taken to qualify as a children's nurse and should increase the numbers coming through the system.

The Tánaiste will shortly announce how the report of the expert group on midwifery and children's nursing education can best be implemented. She welcomes the fact that the hospital has established links with similar institutions outside of the country and would encourage them to explore this option for courses in specialist and expert practice.

I assure the parents and extended family of Róisín Ruddle that every possible measure will be taken to ensure that all the intensive care beds in Our Lady's Hospital are staffed and available to those children who require access to them.

Services for People with Disabilities.

Caoimhghín Ó Caoláin

Gabhaim buíochas don Cheann Comhairle as an deis chun na ceiste seo a phlé. In an adjournment debate on 29 January 2003 I called upon the Minister for Health and Children to act as a matter of urgency to address the severe staffing shortage at St. Mary's residential care facility at Drumcar, County Louth, and to ensure that the residents at the centre had all the personnel and other resources they needed to live with dignity and safety.

Thousands of people, including the families of more than 250 people with physical and intellectual disabilities then resident at Drumcar, were sick with worry about the welfare and safety of their loved ones. A consultant's report had just been published which highlighted the unacceptable conditions for many residents in Drumcar as a direct result of understaffing. Understaffing led to inadequate supervision, inappropriate mixing of residents with very different abilities and disabilities, including very aggressive individuals with passive and introverted individuals, the overuse of restraints in some cases, the leaving of some residents locked up and unattended at night and increased risk of mortality from fire.

The report identified the need for 94 additional staff to cater for all the needs of the residents. Following this report there was a concerted campaign for increased funding for more staff. I played a part in that lobby and I welcomed the outcome when agreement was reached with the Department of Health and Children for the appointment of 30 extra staff at St. Mary's. The extra staff commenced work in April 2003 and were specifically hired to ensure there were sufficient numbers on night duty. This was to address fire and other safety risks for residents at night. A key part of the agreement with the Department of Health and Children and the North Eastern Health Board was that the other issues would be addressed, including the provision of the remaining 64 staff required.

I will cite a note by the management of St. Mary's, which is under the auspices of the Hospitaller Order of St. John of God:

We remained hopeful that the funding for the remaining 64 staff would be approved over the following two years.

During the past two years, because of the serious risk to the safety of the clients and staff on day duty, we were left with no alternative but to take on extra staff without funding which resulted in overspends in the nursing pay area. This excess in expenditure was funded through stringent cutbacks in other areas, and vacancies in areas such as speech therapy, social work, medical registrar and administration. The planned programme of building maintenance and painting had to be suspended and this has impacted negatively on the quality of the environment for the clients, and will ultimately cost a lot more to restore in the future.

In 2004, both ourselves and the NEHB experienced substantial shortfalls in the funding to meet the extra cost of the various pay awards, and like other health agencies we had substantial value for money and other cutbacks imposed on our allocation. We have now reached the stage where we have exhausted all options internally to meet the shortfall.

The very grave situation facing the North East Services was discussed with the North Eastern Health Board on the 10 November 2004 and the Board requested us to conduct a review of the situation, and advise them of the options which we would have to consider to deal with the situation. We did this over the following weeks and informed the Board in December of the various options. The Board passed our concerns on to the Department of Health and Children and a meeting was arranged with the Health Service Executive on 1 February 2005.

Following that meeting on 1 February between the HSE Northeast and St. John of God Northeast Services it was agreed to use the existing joint partnership forum to develop a strategy on how best to continue the implementation of the Sale and Oreschnick Report to address the outstanding priority concerns regarding health and safety issues and critical staffing levels at St. Mary's Residential Services.

It is expected to complete this process within the next three weeks. In the meantime St. John of God Northeast Services has undertaken to defer the decision around the suspension of respite service provision in St. Mary's until February 28 2005.

Aware that my time has marched on, I will conclude by appealing to the Minister for Health and Children to ensure that the outcome of this process is the approval of the full staff complement, namely, the 64 staff identified more than two years ago, funding for same and the restoration of all services lost through the unacceptable delay in fulfilling commitments already given.

As the sibling of someone with Down's syndrome who has spent many years in Drumcar, I believe that it is a wonderful facility only because of the great dedication of the hospitaller order and staff at the site. It requires and deserves a wholehearted and fulsome response from the Department. The loss of respite would be a devastating blow to countless families and I do so appeal.

Mr. S. Power

On behalf of my colleague, the Tánaiste and Minister for Health and Children, Deputy Harney, I thank the Deputy for raising the matter and giving me the opportunity to outline the position with regard to St. Mary's residential care facility, Drumcar, County Louth. I appreciate the Deputy's personal interest in the matter.

The Department has, since 1997, allocated a significant level of funding across the disability sector which has resulted in significant and unprecedented developments in the quality and quantity of the health related services being provided to people with disabilities. With regard to the matter raised by the Deputy, in June 2002 St. Mary's, Drumcar, was served with formal notice of industrial action by the Irish Nurses Organisation because of the staffing position in its residential services.

As requested by the order, the services of the Labour Relations Commission were availed of. One of the proposals to emerge from the conciliation conference was to conduct an independent review of the staffing of the residential services at St. Mary's. It was agreed that this review would be conducted by Diana Sale and Bob Oreschnick, 1066 Consultancy and Healthcare Consultancy Limited. They were commissioned by the order to undertake the work. The report was finalised on 13 November 2002.

Statutory responsibility for the provision of intellectual disability services, including the funding of the Drumcar services, lay with the then North Eastern Health Board. Following publication of the report, the board indicated that there was insufficient funding available to it to implement the recommendations contained in the report. Following discussions between the Department, the North Eastern Health Board and the St. John of God order in February 2003, agreement was reached on the provision of funding to enable the order to proceed with the immediate recruitment of 30 additional staff. The initial investment, amounting to approximately €l million, was intended to address the priority issues identified in the Sale and Oreschnick report around quality of care and health and safety.

Agreement was reached on a process by which the implementation of the recommendations contained in the report would be progressed as a matter of priority as resources permitted. As it has not been possible to provide further additional funding in 2004, both the order and the North Eastern Health Board have expressed anxiety regarding funding for the further implementation of the report, which recommended a total of 94 additional staff.

As the Deputy is aware, the Health Act 2004 provided for the Health Service Executive which was established on 1 January 2005. Under this Act, the executive is required to manage and deliver, or arrange to have delivered on its behalf, health and personal social services. Following a meeting held on 1 February 2005 between the Health Service Executive north east and St. John of God north east services, it was agreed to use the existing joint partnership forum to develop a strategy on how best to continue the implementation of the Sale and Oreschnick report to address the outstanding priority concerns regarding health and safety issues and critical staffing levels at St. Mary's residential services. It is expected to complete this process by the end of the month.

In the meantime, St. John of God north east services has undertaken to defer the decision around the suspension of respite service provision in St. Mary's until 28 February 2005. The Health Service Executive north east disability services and St. John of God north east services will arrange to keep parent representatives abreast of developments in the process. Both parties are hopeful of a positive outcome.

Schools Building Projects.

Mr. S. Ryan

It is with a deep sense of frustration that I raise this issue. Children in the Donabate-Portrane area urgently need a post-primary school on the peninsula. The Department of Education and Science is well aware of the position and a decision to proceed with a school in the area is overdue. It is now a matter of urgency as we are approaching a crisis.

Over the years the Department has taken the view that the second level requirements of students from Donabate and other towns and villages such as Lusk and Rolestown and Ballyboughal can and should be met in established schools such as Loreto College, Balbriggan, St. Joseph's, Rush, Malahide community school and in Swords, Fingal community college, St. Finian's College, Christian Brothers and, to a lesser extent, Loreto College. In recent years, this list has extended to include St. Mary's, Baldoyle, and Portmarnock community school.

In September 2003, I had reason to raise in the House the circumstances of 160 second level students who travelled by rail from Donabate to schools in Portmarnock, Malahide and Baldoyle. Students carrying schoolbags were forced to jostle with other commuters to try to get through the doors of trains which were already packed by the time they reached Donabate. Some children were left on the platform when the train departed and on at least one occasion a student was thrown off the train on to the platform by a frustrated adult commuter endeavouring to get to work. While this sad situation has improved with the provision of additional train carriages, a repetition of such events is inevitable given the increased number of people using the rail service and the fact that no further capacity will be available on the trains for the next four years.

The population of Donabate, like most other towns in Fingal, the fastest growing area in Ireland, has increased substantially in recent years — Donabate's population is expected to increase from 5,000 to 25,000 over the next ten years. A recent door to door survey carried out by Donabate-Portrane second level school committee indicated that on the basis of the existing primary school population, 725 second level places will be required by 2007.

The boom in housing development in Fingal, without the necessary infrastructures, such as schools, is causing distress and havoc for parents. The schools which children attended over the years, such as Balbriggan, Malahide and other schools, are full of students from their immediate catchment areas. "Students from Donabate need not apply" is the message parents get when they phone the schools. That is a reluctant policy of the schools boards of management. It is patently obvious, therefore, that a crisis is quickly developing.

The Minister and the Department are fortunate in that a suitable site can be acquired from the local authority, Fingal County Council, for this school. In fairness to the council, the need for a second level school in Donabate has been identified and provided for in the development plans for the area. Following repeated representations on this issue, I received the standard reply that a new school planning model will be piloted in five areas, including north Dublin, encompassing Donabate. I have no doubt I will get the same response this evening. I am concerned that this planning model — to date we have received no indication when its interim report will be available — will be used as an excuse not to take, or to delay, the decision urgently required for Donabate to commence the planning process for a second level school.

It is important we do not delay this model process because, on the basis of previous reports, I believe a further consultation process could be set in train and it could go on for another year. Let us make a decision. It is patently obvious that there is a need for a school and let us give it the go-ahead. It could take another five years to provide it but let us get it started.

Mr. S. Power

I thank Deputy Ryan for raising this matter as it provides me with an opportunity to outline to the House the overall strategy of the Department of Education and Science to address the future requirements in both the primary and post-primary sectors in the Donabate area.

At the outset, it is important to note that the school planning section of the Department works closely with the four local authorities in the Dublin region in monitoring demographic changes and assessing the likely impact of planned new housing developments. A dedicated forum, the Dublin school planning committee, chaired by the school planning section of the Department of Education and Science interacts with the Dublin local authorities in this regard. This forum comprises representatives of the patron bodies of primary schools.

The Dublin school planning committee acts as an initial point of contact where local authorities can signal to the Department and the patron bodies anticipated demand for school provision. Detailed discussions regarding reservation of sites and scale and timeframe for developments also take place at this forum. The issue of the provision of a post primary school for Donabate has been discussed at this forum.

A decision on the need for a new school in any given area will involve further separate detailed consultations with a local authority regarding the likely timescale for the actual delivery of the housing developments together with an ongoing assessment of the capacity of existing schools to meet anticipated demand. I am pleased to inform the Deputy that this process is well under way with the local authority in regard to the Donabate area.

In addition, as the Deputy will be aware, a new school planning model involving published area development plans is being piloted in five areas over the current school year. Donabate is included in the pilot scheme as part of an overall plan for the north Dublin, east Meath and south Louth area. This particular area was chosen in recognition of its rapidly developing nature and the pressure which is being brought to bear not only for post primary school places, but for primary places as well. The need for a new post-primary school is also being considered in the context of this plan.

The purpose of this new approach to school planning is to ensure that, in future, the provision of school infrastructure will be decided only after a transparent consultation process. In this regard, parents, trustees, sponsors of prospective new schools and all interested parties from a locality will have the opportunity to have their voices heard in the process.

Arising from this process, an individual plan will set out the blueprint for the future of educational provision in an area which will be the touchstone against which all decisions in relation to capital investment will be made for the next decade. The draft plan for north Dublin, east Meath and south Louth area is nearing completion in the school planning section of the Department and the Department of Education and Science hopes to be in a position to publish it shortly.

I assure Deputy Ryan that the Department is keenly aware of the developing nature of the Donabate area and is anxious to ensure that its educational infrastructural needs are met in a timely manner. The Minister for Education and Science is confident that the planning process in train will provide a strategic response to those needs.

The Dáil adjourned at 5.20 p.m. until 2.30 p.m. on Tuesday, 15 February 2005.

Dáil Éireann díospóireacht - Thursday, 10 Feb 2005