Public Sector Staff Recruitment

Ceisteanna (1)

Billy Kelleher


1. Deputy Billy Kelleher asked the Minister for Health the consultations he has had with the Departments of Public Expenditure and Reform, and Children and Youth Affairs with regard to the recruitment embargo in the health service; and if he will make a statement on the matter. [21598/14]

Amharc ar fhreagra

Freagraí ó Béal (8 píosaí cainte) (Ceist ar Health)

The purpose of the question is to elicit information about discussions the Minister has had with the Minister for Public Expenditure and Reform and the Minister for Children and Youth Affairs with regard to the recruitment embargo and its impact on front-line services. We all accept that when the downturn of the economy came upon us abruptly, there was a necessity to try to stabilise the public finances. The embargo on recruitment is always a blunt instrument but it becomes more blunt as time goes on. I would like the Minister to inform us about the discussions he has had to replace front-line services in particular.

The Government has decided that the numbers employed across the public service must be reduced to meet fiscal and budgetary targets. The Deputy acknowledges this. The health sector must make its contribution to that reduction. The recruitment embargo, or moratorium, has achieved substantial reductions in employment in the public health service.

The number of staff employed by the health service has reduced from 111,770 whole-time equivalents, WTEs, at the end of March 2009 to 99,959 WTEs at the end of December 2013, a reduction of 10.6% or over 11,800 WTEs. The reduction in employment numbers was monitored by my Department in conjunction with the HSE and the Department of Public Expenditure and Reform through the joint employment control monitoring committee up until the end of 2013. The functions of that committee have now been subsumed into the work of a joint monitoring committee on finance, performance and employment which has representation from the HSE, my Department, the Department of Public Expenditure and Reform and the Department of An Taoiseach.

The recent establishment of the Child and Family Agency resulted in over 3,000 WTEs being transferred from the HSE to the Child and Family Agency on 1 January 2014. The new Child and Family Agency will also be subject to the recruitment embargo or moratorium. The health service is further required to cut employment levels to 94,209 WTEs by the end of 2014 from a work force of 96,582 WTEs at the end of January 2014 and the HSE national service plan provides for an additional 500 WTE development posts, primarily in primary care and mental health services as well as the filling of development posts funded and approved in previous years.

In order to mitigate the impact on front-line services of the reduction in employment numbers, the priority is to reform how health services are delivered in order to ensure a more productive and cost-effective health system.

Additional information not given on the floor of the House

Therefore, the HSE has been using the provisions of the public service agreements to bring about greater flexibilities in work practices and rosters to achieve more efficient delivery of services. The Haddington Road agreement provided the health service with over 5 million additional employee hours. These hours are being used to replace staff who have left, to allow for further employment reductions and to reduce spending on agency staff and overtime. The agreement also provided for the employment of up to 1,000 nurses on the graduate nurse initiative and 1,000 interns under the support staff intern scheme outside the HSE’s employment ceiling.

Nearly 500 nurses and midwives have commenced employment in recent months on the graduate scheme, with over 200 others currently going through the recruitment process. Almost 250 support staff interns have commenced employment with approximately 700 going through the recruitment process. Subject to approval by senior managers, arrangements are in place in the HSE to allow the recruitment of staff where it has been established that there is an urgent service requirement.

We all accept that the health sector must make its contribution to national recovery but we should not expect those who rely on our health services to make sacrifices over and above what would be considered reasonable. The impact this is having on the broader provision of services is now at a critical stage. The INMO has indicated that current staff to patient ratios in maternity units range from 1:32 in Mayo General Hospital to 1:55 in the Midlands Regional Hospital in Portlaoise which, as we know, is the subject of an ongoing investigation by HIQA into a number of infant deaths. That is an issue of grave concern.

We have seen the leaked report of the review of maternity services in the north west which has set alarm bells ringing, particularly in the context of midwife-led services in some hospitals and obstetrics-led services in others. The dearth of staff in our maternity services is an issue of major concern. We need to see the embargo being lifted in the critical areas. We do not want to see appointments made on a one-on-one basis, but rather a policy reversal in key front-line service areas.

In the short time I have, I wish to address some inaccuracies. The INMO may have its own figures but we have figures which were given to me last week on the ratio of staff to patients at Portlaoise. It is 1:48, which I acknowledge is far too high. We have a task force on nursing and midwifery which will address this issue in terms of getting the skills mix right and determining safe ratios.

The so-called "leaked report", which was addressed by me in this House a number of months ago in the context of maternity services in the north west and west, has no standing of its own. It will feed into the national review of maternity services and there are no plans to close any maternity unit. I want to make that clear on the floor of the House.

That is not what the report suggests.

The Deputy raises an important point but the moratorium is being used in a focused fashion here. We employed 750 additional nurses last year. We want to have the nurse ratios and the skills mix done properly. We have a situation where we have some model four hospitals with nine nurses per health care assistant and others with 2.8 nurses per health care assistant. We have doctors doing nurses' work, nurses doing work that health care assistants could do and a whole mismatch of peoples' skills sets to the jobs they are being asked to do. That is where the future savings and efficiencies are.

The issue of maternity services must be addressed. We all accept that the national review is ongoing but in the meantime we are reduced here to arguing about whether the ratio is 1:48 or 1:55 in the Midlands Regional Hospital. The bottom line is that whether the ratio is 1:48 or 1:55, it is still too high. That issue must be addressed. I do not mind being slightly inaccurate but the Minister must also acknowledge that a ratio of 1:48 is unacceptable by any standard.

The recruitment embargo is a blunt instrument. We need a change in policy in the context of front-line services. Rather than the HSE seeking permission to appoint on a one-on-one basis, there should be a policy reversal in key areas to ensure the safe delivery of services.

I assure Deputy Kelleher that there will be no policy reversal. What is being done is what I have just described. A far more refined approach is being taken by focusing the staff in the places they are needed and getting the skills mix right. I already acknowledged that 1:48 is far too high but we must examine the roles of those working in our hospitals and determine how we can make better use of the staff we have. We must find ways to support staff using other staff so that we can provide the safest possible care for patients. That has been my absolute priority in the national service plan.

I have no problem with people pointing out the difficulties that are in the system because I want to know about and deal with them. However, I want to deal with them in a planned, evidence-based fashion. I hope that Deputy Kelleher will accept that the situation in the midlands in particular is one we inherited and which has been festering away for decades.

Medical Card Reviews

Ceisteanna (2)

Caoimhghín Ó Caoláin


2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if he will elaborate on the third tier medical card and other measures of which he has spoken in view of the loss of discretionary medical cards by many thousands of citizens in need; and if he will make a statement on the matter. [21352/14]

Amharc ar fhreagra

Freagraí ó Béal (12 píosaí cainte) (Ceist ar Health)

I ask the Minister to explain his recent reference to a "third tier". Of what is it a third tier? I also ask him to refer to other measures he has spoken of in the context of the loss of discretionary medical cards.

While there has been a reduction in the number of discretionary medical cards, I wish to assure the Deputy that there is no policy to reduce the number of medical cards issued where discretion is involved in the assessment process. The fact is that many people who used to hold discretionary cards have been granted medical cards on income grounds because they now fall within the means thresholds. Only a very small proportion of people with discretionary medical cards who have been reviewed recently have been found to be ineligible for a medical card. Of the discretionary cards in circulation in 2011, less than one tenth have been found to be ineligible on review. On the other hand, even where medical expenses have been taken into account, some people have been found to be ineligible because their net income is in excess of the means thresholds, sometimes by hundreds of euro per week.

In accordance with the legislation, medical cards are awarded to persons who suffer undue financial hardship in the arranging of GP services including where this arises as a result of a disease or an illness. The HSE established a panel of community medical officers to assist in the processing of applications for medical cards where the income guidelines are exceeded but where there are difficult personal circumstances, such as an illness or physical disability. The medical officer reviews evidence of necessary medical expenses provided by the applicant. As appropriate, he or she liaises with general practitioners, hospital consultants and other health professionals so that costs relating to the health circumstances of the applicant can be taken fully into account.

The Minister for Health and I are conscious of the difficulties faced by the relatively small number of people who have been found to be ineligible. At his request, the HSE is currently examining how individuals who are not entitled to a medical card could still receive services that meet their needs. This examination relates to all of the services and supports provided by the HSE and with regard to as much flexibility as is available at a local level. Additional information will be provided and local information points will be established at major health centres around the country where members of the public can obtain comprehensive information and support in accessing the full range of supports from the health services. The objective is to maximise the supports available for patients and families.

Appropriate notice is also being considered as part of the review for existing medical card holders who may no longer be eligible on renewal, but where serious medical conditions or profound disability continues to exist in the household. The clear intention is to maximise the supports that can be provided in each case to the fullest extent possible. The HSE is seeking to find the best way to achieve this in order to ensure families will receive the support they need.

The Minister up until very recently has refused to recognise the problem. I believe he was prompted into doing so by a recent meeting of his parliamentary party. He floated what I can only describe as a vague notion of some kind of "third tier" of services. The Minister of State made no reference to that in his reply, yet that is the core of the question I have posed. I asked that he would elaborate on the third tier concept. Initially, it was thought it was a third tier medical card but that was discounted in an interview in last week's The Sunday Times.

What is this third tier that was referred to by the Minister? Has he any notion of the distress the loss of, or fear of losing, their medical card is causing people? That fear is absolutely huge, as I am sure will be confirmed by canvassing Deputies across the board. Will the Minister of State reverse the cuts that have taken place and restore the essential discretionary medical practice that has applied heretofore as a central feature of the scheme, in recognition of the hardship now being imposed?

Nobody on this side of the House has ever refused to recognise there is an issue in regard to discretionary medical card provision. As I indicated in my reply, we accept that some people have been found to be ineligible following a review of the medical card granted to them under the discretionary process. We are not denying there is an issue, but we have sought to show that the extent of the problem is nothing like as widespread as has been suggested in some quarters. Something in the order of 6% of persons who held a discretionary medical card in 2011 have lost it as of 2014. It certainly is a problem for the people who are impacted, as I acknowledged last night during the Private Members' debate. Where people who had access to a card for a lengthy period lose it, there is a real dilemma for them, particularly in circumstances where there is a disability or illness.

The Minister has asked the Health Service Executive to explore ways of introducing packages of integrated care to ensure people who have lost access to a medical card can still access the services they need. That is what is happening. As to reports in the media of third tiers, second tiers or any other tiers, I cannot speculate about that.

Of course, the only real tears, as opposed to tiers, are those of the families who have been left in distress. The notion that there is no such thing as a discretionary medical card is belied by the Minister of State's own figures, given in parliamentary replies, which show that in March 2011, 97,120 people were in possession of full medical cards or GP visit cards on a discretionary basis. By March of this year, however, that number had fallen to 78,310, a drop of nearly 19,000 or almost one in five. In percentage terms, that is closer to 20% than 6%. These are the figures the Minister of State has given us and they show that the situation is much more serious than he suggested last night and again this morning.

Surely we can be of one voice on this issue? We are asking that the HSE treat with due respect and compassion all applicants for medical cards or renewal of medical cards, taking fully into account not only incomes but the other clear burdens imposed by medical conditions, illnesses and disabilities. That real cost must be factored in.

I am sure the Deputy does not intend it, but the figures he has given are inaccurate. Of the 77,925 or so people who were in possession of a discretionary medical card in March 2011, one third still have a medical card on a discretionary basis and approximately one half still have a medical card but not through the discretionary route. This is what Deputies opposite continue to ignore - perhaps deliberately in some cases, although not in the case of Deputy Ó Caoláin. Of the March 20011 cohort, 19% no longer have a medical card. However, this is made up of 3% who are deceased, 7% who did not respond to correspondence from the HSE and 2% who did not complete the review process. That leaves approximately 6% or 7%, not 19%, who were found to be ineligible for a medical card. Somewhere between 5,500 and 6,000 persons, not 19,000, have been deemed ineligible.

I am not for one moment seeking to diminish the effect that loss has on people. That is why the Minister has asked the HSE to take steps to address the issue. However, I appeal to Deputies opposite that we get the numbers right. I realise we are in electioneering mode, but we must have the numbers right so that we can all work off the same pitch.

It is the Government that is concerned about the elections.

Senator Marc MacSharry is in very good electioneering mode.

This is not about elections.

Deputy Ó Caoláin is out of time. We have already had two supplementary questions.

This is about facts. I am citing the Minister of State's own figures.

The Deputy is misrepresenting them.

HSE Legal Cases

Ceisteanna (3)

John Halligan


3. Deputy John Halligan asked the Minister for Health the cost of medical negligence claims to the State in 2013; the amount of that sum that went on legal fees for those defending the Health Service Executive; his views on whether, in cases of negligence at birth, the HSE has a tactical policy of deliberately delaying or withholding admission of liability, resulting in a lengthy litigation process for vulnerable families; his views on whether a radical overhaul is needed of the way clinical negligence is managed; and if he will make a statement on the matter. [21354/14]

Amharc ar fhreagra

Freagraí ó Béal (7 píosaí cainte) (Ceist ar Health)

Will the Minister comment on the cost to the State of medical negligence claims in 2013 and the extraordinary sums paid in fees to persons defending the Health Service Executive in such cases? Will the Minister admit that in cases of negligence at birth, the HSE has a tactical policy of deliberately delaying or withholding admission of liability, resulting in lengthy litigation processes for vulnerable families? Does he agree that we need a radical overhaul of how criminal negligence is managed?

I thank the Deputy for raising this important issue, which is a cause of grave concern to me. As an underlying principle, compensation moneys should go to those who have suffered harm, not to members of the legal profession.

The cost of clinical indemnity scheme claims under management with the State Claims Agency, SCA, in 2013 was €119.3 million in total. This figure relates to costs transacted during the period and includes damages paid, legal fees and other expert costs such as medical expert fees. Breaking down the total cost, damages to patients accounted for €81.6 million, State Claims Agency legal costs and expert costs were €17.1 million, and plaintiffs' legal costs and expert costs amounted to €20.6 million.

The management of clinical negligence cases taken against the Health Service Executive is delegated to the SCA, which has a statutory mandate to investigate and manage these cases to completion. I am advised that the SCA, wherever it is proper to do so based on expert medical and legal advice, admits breach of duty at the earliest possible opportunity to avoid distress to patients and their families. Many of these cases, however, particularly those involving catastrophic injuries, are very complex in nature and require time to investigate the liability and causation issues. This inevitably involves some delay before a formal admission of liability, if appropriate, can be made.

A national policy on open disclosure was developed jointly by the HSE and the State Claims Agency and launched in November 2013. The policy is designed to ensure an open, consistent approach to communicating with patients and their families when things go wrong in health care. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event. Implementation of the policy across all health and social services has now commenced by the HSE.

Ireland currently has no express protective legislation to assist the open disclosure process. However, it is intended that this situation will change with the upcoming health information Bill which I expect to publish in early 2015. That legislation will contain a number of measures to promote patient safety, including a provision to encourage open disclosure by affording some degree of protection for health care personnel. This is consistent with the report of the commission on patient safety and quality assurance of 2008. It is also in line with the recommendation in a consultation paper published by the Law Reform Commission in 2008 that "a statutory provision be considered which would allow medical practitioners to make an apology and explanation without these being construed as an admission of liability in a medical negligence claim".

The Minister is no doubt familiar with the case of Dylan Gaffney Hayes from Waterford who suffered serious injuries leading to cerebral palsy at his birth in 2007. A case of medical negligence was taken by his parents and it took three years for the HSE to admit liability, after which the family had to wait another year for damages to be assessed. The damages hearing took 11 days, which was a harrowing experience for the family, particularly Dylan's mother, Jean, who was forced to relive on the stand the whole ordeal of her little boy's birth. Prior to the case being taken, an independent medical investigation concluded that Dylan's injuries were due to mismanagement of his mother's labour, but the State Claims Agency put in a defence denying this. Three years later, at a substantial cost in legal fees and huge emotional cost to the family, the court upheld the original findings of the medical investigation.

The HSE has paid out €255 million in legal fees since 2005 contesting negligence cases, which is approximately 40% of the overall cost of such claims. Ten barristers shared an outrageous €3.15 million in fees relating to medical negligence cases last year, all of which were settled out of court.

It is scandalous.

I cannot stand over the last figures referred to by the Deputy. I do not know, for example, whether the legal fees paid out by the HSE include child care cases, on which a great deal of money was paid out in the period in question. I will check out those details. What is of great concern to me - it is something I pointed out repeatedly when I was on the other side of the House - is that up to one third of the money we pay out in compensation goes on legal fees as opposed to directly to the victims who have suffered as a consequence of misadventure or medical negligence.

If we want to learn from mistakes made, we need open disclosure. I know from my own professional career that in most instances what people want is the three As: an apology for what went wrong, an acknowledgement that something did go wrong, and an assurance that it will not happen again because things are going to change. In most cases that is what people want but they are driven to law because of the frustration they experience through a system that is very defensive and legalistic. That is the reason we need a patient safety agency and the reason I am intent on setting it up this year on an administrative basis, but it will be given statutory footing to be independent. It will be seen as the patient's advocate, the agency to go to when one has a complaint whether it is because somebody was rude or because somebody died. That agency will be one's friend and one's advocate and will advise on how best to pursue the outcome.

It has been claimed that the State could save millions of euro by bringing medical negligence claims under the remit of the Injuries Board. The Minister and Fine Gael spoke about that issue and the Minister for Jobs, Enterprise and Innovation, Deputy Richard Bruton, announced plans to set up a medical injuries assessment board, based on the Injuries Board. How advanced are those plans? Does the Minister support the idea of strict liability for medical injury with compensation assessed by an independent assessment board in such instances?

In principle, I have no issue whatsoever with what the Deputy is suggesting. I am exploring ways of getting the law out of this in terms of the adversarial element and looking at the New Zealand process where the maximum amount paid out is €100,000. It seeks to remedy the effects of the misadventure from the patient's point of view so that the person is supported in the community. Much of the concern here is that we have not, perhaps, supported people who have catastrophic injuries, cerebral palsy and other conditions in a manner in which we could and should support them. If the money was diverted into the community service to support people, they would not feel the need to go to court as much as they do.

The other area for which we have to legislate is around the issue of ongoing payments rather than one big lump sum at the beginning. Clearly, it is not possible to predict with certainty how well somebody will progress or how long they might survive. All of these issues are being looked at by my Department. An area I am particularly concerned about is vaccination. Vaccines are given in good faith, they are produced in good faith and are taken in good faith, yet we know that in certain instances people will have bad reactions. I believe we should support those people, not force them to go to law for compensation.

Mental Health Commission Reports

Ceisteanna (4)

Colm Keaveney


4. Deputy Colm Keaveney asked the Minister for Health the actions he has taken following the findings of recent audits into the compliance of the notification and investigation of incidents of sudden, unexplained death of persons in community mental health services with legislative requirements and Health Service Executive policy and procedures; and if he will make a statement on the matter. [21599/14]

Amharc ar fhreagra

Freagraí ó Béal (7 píosaí cainte) (Ceist ar Health)

The audits referenced in the question highlight that there are 18 recommendations. Will the Minister share with the House what action plans he will put in place with respect to the recommendations set out in the audits? For the benefit of the House, the audits involve an investigation into community and mental health services, into approved centres and into the community setting which deal with the compliance or the non-compliance of obligations to report to the Mental Health Commission where, tragically, death by suicide by a person within the mental health services takes place. I appreciate that is not entirely preventable within the mental health service. However, it is essential that we get to answer this question if we are to learn anything from what we would regard as the greatest public health crisis in the country, which is death by suicide.

It is important that mental health services, as with all parts of the health service, are subject to periodic review or audit where issues of potential concern are identified. Such review processes facilitate services to improve the quality and safety of the care and treatment provided, by identifying any matters of concern and making recommendations as to the steps necessary to address these.

In 2013, as part of its patient safety and quality process, the HSE Mental Health services and Quality and Patient Safety Directorates requested an audit of compliance with regulatory requirements and HSE policies and procedures in relation to the notification and investigation of incidents of sudden, unexplained deaths of persons in community mental health services.

The HSE audit report was completed on 15 January 2014. The report concluded that, based on the information submitted, the audit team could not provide assurance that incidents of sudden, unexplained death of persons in community mental health services were being notified in accordance with HSE policy and procedures, nor could it provide assurance that incidents of this nature were investigated using the systems analysis methodology.

The audit report made a series of detailed recommendations in relation to the notification, recording and investigation of sudden unexplained deaths of users of mental health services. The HSE is taking steps to ensure that each of these is addressed. In March 2014, the national director of mental health services issued a memorandum to all relevant managers, re-emphasising the requirements in relation to the reporting of sudden unexplained deaths. Work is under way in conjunction with the Mental Health Commission in respect of two recommendations. The Executive is also working to ensure that the other shortcomings identified are addressed through appropriate performance management and service improvement processes.

I share the Deputy's concern and I find this totally unacceptable. Sudden deaths should always be recorded and explored. This is how we find out if there is an unintended consequence from some of the treatments that some of our patients take. This is what came across years ago with one particular drug which was causing cardiac arrhythmia problems. Had it not been investigated and the issues recorded, it would never have come to light. I take this matter extremely seriously and thank the Deputy for raising it.

I thank the Minister.

I welcome the Minister's alarm. Only last week, officials from the Minister's Department telephoned my office seeking the report. It is a source of great concern that the consistency with the Minister's alarm, with respect to the officials in the Department, would raise some questions in light of the fact that somebody from the Opposition benches had to be contacted to identify the report to which I have referred. Of the two audits, one was involved in a community mental health service where there are some particularly startling details. Fewer than 25% of the incidents involved in the investigation were notified in accordance with the law and half of the incidents investigated did not provide for a review with respect to the deaths involved. The standard review was performed but, largely, there is no standardised approach within the service. Also there is no evidence to suggest that an operational plan was developed, subsequent to establishing an investigation, around what had been identified in the investigation was provided for within that centre. Will the Minister comment on the fact that we have had 18 recommendations since January? What actions has he taken with respect to the two audits? I would be alarmed if this report only came to his attention last week.

I assure the Deputy there are recommendations and they are being put in place. The HSE mental health division, in conjunction with the Mental Health Commission, should review the completeness of the notification circumstances to ensure that sudden unexplained deaths in persons in receipt of services for more recently developed service problems will be captured, that is, home care and assertive outreach programmes, etc., that the HSE mental health services should ensure that a record of all patients notified of an incident of sudden unexplained death is kept, that the HSE mental health services should ensure that incidents of sudden unexplained deaths of persons in community and mental health services are investigated and that the systems analysis methodology is applied, and the HSE mental health division should ensure that services are fully aware of and compliant with the process involved in documenting the development, monitoring and review of service users' individual care plans, as set out in the Mental Health Commission document on individual care planning in 2012. The full list of recommendations is available and can be forwarded.

It is a fact that there has been a general failure to investigate the contributory factors to the deaths involved. The report clearly indicates that the Department's failure to adhere to the legislation and the regulation has resulted in a collapse in a standardised approach. That only one in eight of the investigations undertaken was consistent with the approach set out by the systems analysis methodology, to which the Minister referred, is unacceptable. If we are to learn anything from the crisis within the country with respect to death by suicide we need to establish where the systems are breaking down within the HSE and why validation of compliance was not possible in cases due to, for example, the lack of supporting documents, maintaining files and adhering to standing operational procedures.

We are failing the most vulnerable people by failing to ensure we follow regulation procedure in this respect.

I take this matter very seriously. I have pointed out what has been recommended and note the word "should" appears a lot. As far as I am concerned, the word "should" will be replaced with the word "will". These are the most vulnerable people and they cannot speak for themselves. Therefore there is a requirement for us to look out for and speak up for them. I and the Minister of State, Deputy Lynch, will ensure these audits are carried out properly, that investigations are properly supervised and reported and that we get proper information speedily. A range of consequences must be developed for those who do not perform as per their contract and duty.

Maternity Services

Ceisteanna (5)

Caoimhghín Ó Caoláin


5. Deputy Caoimhghín Ó Caoláin asked the Minister for Health if a report has been prepared on an infant born at Cavan General Hospital in November 2012 who was subsequently transferred to a neo-natal unit at a Dublin hospital and died there; if the report has been presented to him; and when same will be published; and if he will make a statement on the matter. [21353/14]

Amharc ar fhreagra

Freagraí ó Béal (10 píosaí cainte) (Ceist ar Health)

I seek to establish whether a report has yet issued on an investigation undertaken into the tragic loss of a newborn life, following a C-section at Cavan General Hospital in November 2012.

I note the reply to this question is quite long. Therefore, in view of the unsatisfactory nature of having to cut the Minister off half way through on an issue such as this, can the Minister and Deputy Ó Caoláin agree that we will allow the Minister give the full reply and that we will take just one supplementary question? Otherwise, I will have to cut the Minister's response off half way through.

Would it be allowed into the record?

Yes, but if the Deputy wishes to hear the full reply, I am prepared to allow the Minister the time for it.

I believe that would be appropriate.

I thank the Ceann Comhairle and the Deputy for their agreement.

I am conscious of the personal tragedy for the family at the centre of this sad incident and am very anxious not to intrude on its privacy. I would like to express my sympathy to the family concerned on the sad loss of their child.

I am advised that following an obstetric clinical incident in Cavan General Hospital in 2012, an external review was commissioned by the Health Service Executive area manager. A team from the National Maternity Hospital was identified to carry out the review of the circumstances surrounding the clinical management and care of an obstetric patient and her baby. The review team met with the family and has taken its views on board and these views will be included in the overall report of the team. I am informed that a final report from the external review committee will be submitted to the HSE in the coming weeks. The general manager of Cavan General Hospital will liaise with the family concerned.

My Department is ensuring that the actions required to implement the recommendations in the HIQA report into the death of Savita Halappanavar at University Hospital Galway are being undertaken across our health services, with a view to improving patient safety and providing a more patient-centred model of care. A second progress report by the HSE's national director of acute hospitals, who has been assigned responsibility for this body of work, was forwarded to my Department on 2 May. Progress in implementing both the local and the national recommendations is well under way and will continue throughout the year.

Following on from the authority's report I have listed five key priorities in regard to patient safety. Patient safety has been made a priority within the HSE’s annual service plan through specific measures focused on quality and patient safety, including health care associated infections, medication safety and implementation of early warning score systems. Officials of the Department of Health will meet the HSE each month to review progress on the service plan and patient safety will be a standing item on that agenda. My Department is leading the development of a code of governance which will clearly set out employers’ responsibilities in regard to achieving optimal safety culture, governance and performance. It is expected that a code of governance will be developed during 2014. I have written to the Chairman of HIQA to ensure that my patient safety priorities are included in the monitoring programme against the national standards for safer and better health care. My Department, in conjunction with the HSE, will develop a new national maternity strategy this year. This will provide the strategic direction for the optimal development of our maternity services to ensure that women have access to safe, high quality maternity care in a setting most appropriate to their needs; and I have instructed the national clinical effectiveness committee to commission and quality assure four priority national guidelines on sepsis, clinical hand-over, maternal early warning score and paediatric early warning score. This body of work is in progress.

I requested the chief medical officer of my Department to prepare a report following a "Prime Time Investigates" programme relating to Portlaoise Hospital maternity services on 30 January 2014. The critical question the report addresses is whether the service provided by Portlaoise Hospital maternity services can be said to be safe from now on and into the future given the events that were reported in public and Portlaoise Hospital's response to these events.

Among the overall conclusions of the report was the conclusion that families and patients were treated in a poor and, at times, appalling manner with limited respect, kindness, courtesy and consideration. In addition, the Portlaoise Hospital maternity service could not be regarded as safe and sustainable within its current governance arrangements as it lacks many of the important criteria required to deliver on a stand-alone basis a safe and sustainable maternity service. An urgent recommendation was that the Portlaoise Hospital maternity service should become part of a managed clinical network under a singular governance model with the Coombe women and infant university hospital. Pending implementation of this recommendation, the report recommended that a team should be appointed to run the Portlaoise Hospital maternity service. The HSE put this team in place on 28 February last. On the broader maternity issues, it was recommended that other small maternity services should be incorporated into managed clinical networks within the relevant hospital group.

I also requested HIQA to undertake an investigation in accordance with section 9(2) of the Health Act 2007. In addition, HIQA was asked to undertake an immediate assessment of the patient safety culture at Portlaoise Hospital. Wider patient safety recommendations include the introduction of a patient safety statement for services which will be published and updated monthly and the establishment by HIQA of a national patient safety surveillance system. The Board of HIQA has approved the commencement of a section 9 investigation, and published its terms of reference for same on 18 March. HIQA announced the external members of the investigation team on 28 April. The report makes 42 recommendations and 11 overall recommendations, all of which I have accepted. This report will not only inform, but will underpin my Department's planned national maternity service strategy which will be delivered this year.

I take this opportunity to thank Tracey Cooper for her seven and a half years as CEO of HIQA. She is leaving us to return to her native Wales and I wish her well.

The HSE has considered the implications of the report and an implementation group, chaired by the national director of acute hospitals, has been established to oversee and ensure the recommendations of the report are progressed in a timely and effective manner. Progress on implementation of the recommendations will be reviewed by the HSE leadership team at its monthly meetings and a monthly report will be provided to the chief medical officer, CMO. The CMO received the second progress report last week and notes the continued progress in implementing its recommendations.

I join the Minister in extending sincere sympathy to the grieving family once again. However, it was not at the request of the family that I tabled this question, but because another tragic outcome has presented at Cavan General Hospital in the past fortnight. All families in the dependent catchment, including all of counties Cavan and Monaghan, particularly all expectant mothers and women of childbearing age, are concerned to know what has happened. They want to know why these tragic outcomes occurred. They want to know that the lessons, if there are any, are learned and that the prospects of a further bad outcome are eliminated.

Having inquired into the status of the report into the November 2012 event, I have discovered this report is still in draft form and has not been signed off. Why does it take 18 months and more to establish the facts of such an occurrence? Given the facts may well inform future practice within the hospital, would it not be essential to ensure early completion of the investigation and report and the implementation of any recommendations that may be made? I and people generally are alarmed that another sad outcome, where a C-section was also involved, has now occurred and the report on the first incident has not yet been presented.

When will this report be completed and will it be published, even in redacted form? We do not want to encroach on the privacy of the family involved, but surely lessons can and must be learned. This is all about restoring confidence in the excellent staff in the maternity unit in Cavan General Hospital and the systems and processes they employ in the service they provide.

I refer the Deputy to my earlier statement that the family's views will be included in the overall report of the review team and that a final report from the external review committee will be submitted to the HSE in the coming weeks. I agree with the Deputy and share his concern that people would be reassured of the safety of the service.

To make a general point, we have an excellent service, delivered by excellent people, but they are people and to err is to be human.

What we have to put in place is a system that protects patients from human error because human error will always occur and will always be with us. This is why the outcome of this report is so important. It will serve to protect from further incidents of this type and, without being prejudicial, determine whether we can learn from this to ensure that similar things do not occur again or that the service becomes safer. For example, in respect of Portlaoise we know that reports were done and put on a shelf. Nothing was learned from them and the same mistakes were made repeatedly. Certainly, we do not want to see that occur again. I believe that with the introduction of hospital groups and the service being brought into a hub and spoke model we can have available the level of expertise that supports professionals and protects patients.

Will the report be published, even in redacted form, if necessary?

I have no issue with that. I will have to discuss it with the HSE. Certainly, it will be made available to the family, there is no question about that, and then, in conjunction with them, redacted, if it is to be published. I have no issue with that.