Dr. Tony Holohan:

Deputy Kelleher asked about the other organisations involved. As I said at the beginning, we interacted with a number of organisations at a national level. In particular, we know that the State Claims Agency and HIQA had information that gave them cause for concern about the service and they shared their information with us. Some of that data is now in the report, and figure 4.6 is an example.

We also asked some of our national regulators. We asked the Medical Council and An Bord Altranais because they have a relationship with services on the ground and sometimes deal with complaints, so that would give them a perspective on what may be happening in a given service. Also, they have an inspecting role in education and training in services, which would also give them a window on what is happening. We asked them about all issues of this kind. We did get information that allowed us to say that certain organisations at national level had information that gave them cause for concern and that they were raising them with the hospital at a local level.

With regard to staffing in general, I will provide information to complement what the Minister has said. He was correct when he said the report did not say that the staffing issue was an explanation for what happened here. It was saying that it was not the only explanation, which is far more complex. Frankly, staffing cannot explain the situations that we discovered - individual cases that occurred in isolation with no other patients on the ward and with a full complement of staff at that time. It does not explain the behaviours or the way in which staff spoke to, treated or interacted with staff or patients in a given situation.

We do know that there was good reporting. The level of adverse incident reporting was comprehensive in the sense that staff were completing reports, but we think that was part of the overall culture.

The response to patient safety issues was one of completing a form and sending it away to the State Claims Agency. Frankly, it is my personal view that it is not sufficient for a health care professional to discharge his or her obligations to patients in terms of patient safety by writing letters to Ministers or others about staffing levels. That does not mean, however, that it is not appropriate for staff to raise issues at a local level.

Deputy Ó Caoláin specifically asked me for my view on what the INMO has said. I have seen what that organisation has said about staffing levels but I am not aware that the INMO has made any comment whatsoever on the behaviour of staff, which, in my view, was central to the findings and central to the issues before us. While I am not accusing anybody of trying to simplify things, the INMO's interpretation would be, for me, an oversimplification of a very complex story. Deputy Catherine Byrne's analysis is much closer to ours in terms of explaining what happened. We make clear in our report that there was an increase in the number of births which was not matched by an increase in the number of staff. We also make clear that there were difficulties in recruiting staff and that there were leadership positions vacant which, in my view, are very important in explaining some of the findings that were set out in the HSE's own individual reports about supervision, handover, escalation and so forth. We make clear recommendations with regard to Birthrate Plus and a number of other measures that must now be used as a benchmark. There are certainly issues with regard to staffing - I am not saying that staffing is not an issue - but it is not the sole explanation for what happened here. We cannot allow ourselves to conclude that a problem with staffing allows people to abdicate their responsibilities in terms of looking after patients sensitively, kindly and compassionately or reporting harm to patients honestly and openly when it happens, because that is an inevitable consequence of health service delivery.

Deputy Kelleher and others asked whether this is happening elsewhere. As the Minister has said, that is part of the reason for saying that the implications of this report must be examined by the HSE in the context of other similar-sized services. That is also reflected in the recommendations on the investigation that HIQA will conduct. In particular, it is reflected in the recommendation that the hospital groups mechanism should be the direction of travel in the reorganisation of hospital services. There is enough reason for us to say that we should get on with the linking of smaller units into larger units within the hospital group areas.