Billy Kelleher (Cork North Central, Fianna Fail) | Oireachtas source

I thank the witnesses for attending and for their presentations on the report. I compliment Dr. Holohan on his report and on his professional handling of same. I also compliment the Minister on meeting the families. It showed that what is often lacking for families in a time of crisis is a human face. The families appreciated it.

This is just the initiation of a longer and more in-depth review by HIQA. Although we will await the outcome of that report, there were clearly difficulties in Portlaoise hospital. For example, misdiagnoses in the context of breast cancer screening had already been identified. Since 2007, the HSE had been concerned. Dr. Holohan's report points out that other organisations were aware of difficulties within the hospital and that, if the information had been collated, alarm bells might have rang sooner, preventing some outcomes. We will never know. What are those organisations? Are they the HSE, worker representative bodies, clinical professional organisations and so on?

When launching the report in Portlaoise and meeting the families, Dr. Holohan stated that the number of staff was not specifically the issue of concern.

Even though there may not have been staffing problems on the day in question, given the increase in the number of births at the hospital over a sustained period, staff are under pressure all of the time. This suggests that corners start to get frayed, shortcuts are taken and management is challenged. It is a concern if clinicians do not have the time to question and to fill in their reports properly. There appears to be a problem with reportage.

One must conclude that, on the clinical side, people were beginning to indicate that there had been problems with patient safety in the maternity services for some time. From what I can gather from discussions with people involved in the hospital, concerns were relayed by nurses and front-line staff to management several times. That they brought them to local politicians as well is a written fact. While we must hold to account those who should be accountable, it seems that the maternity service was almost operating in isolation of managerial oversight. Will the witnesses comment on this point?

Committee members met the families and saw their emotion at the report's publication in Portlaoise. They were treated in an appalling manner. That such a thing could happen is incomprehensible on a level of basic human compassion and kindness. If a system becomes reactive, insular and sensitive when families face these circumstances, it must be changed.

Was the culture of a lack of openness and co-operation ingrained in all of the staff or just some management? How did it come about? Is it in other maternity hospitals and the health service in general? We have discussed whistleblowers in other forums, but when people, particularly front-line clinicians and patients, raise issues of concern, I have found there to be a resistance in the system to accepting the veracity of those claims and to investigating in more detail as to whether the complaints have merit. At times, we dismiss clinicians who highlight issues of patient safety. Consider the new contracts for general practitioners, GPs, and consultants and the clauses on prejudicing the name of the HSE. Is everything becoming more secretive? If so, it puts more pressure on contract employees of the HSE who want to be open and honest if they believe there are problems. The Garda Síochána is a disciplined force, but it looks like the HSE is one as well. Never should one question authority up the line.

An open disclosure policy would be a major step in the right direction. I am not just referring to cases where the clinicians accept that they got it wrong. Rather, management and the entire system should be open about addressing problems instead of hoping they will go away or can be avoided. I am not making a criticism of any individual. The system just appears to be resistant to any form of accountability. We should not start witch hunts, but if someone is clearly unable to do his or her job, questions must be asked of that person regardless of whether he or she is a manager, a clinician or anything else. I hope that the policy of open disclosure will begin to permeate the organisation as a whole.

Has my time concluded?