Dr. Mary McCaffrey:

I am not aware of any needless deaths due to needless obstetric intervention. I am not aware of any death from suicide because a termination was declined. Deputy Healy's question related to the smaller units. I thought my presentation made it clear that more severe medical cases including cardiac disease are referred to multidisciplinary teams in different units, generally in Dublin. We manage obstetric emergencies in smaller units although the three-man units vary in the number of cases with which they deal. The Waterford unit delivers 3,500 with three consultants, which is admirable. It would not really be considered a small unit. What matters is the skills mix, who is on duty on a particular day and whether an intensive care bed is available. The expertise of the clinician standing at the end of a bed must be acknowledged and he or she must be protected in law to permit the right decision for the particular patient at a particular moment. We must consider the track record of smaller hospitals on maternal death. While I do not want to tempt fate by discussing it, we have a strong track record in the management of patients, whether by referring them to other units or managing them locally.

While the Medical Council has said that a second signature is not necessary, it is always good practice to discuss very complex cases with a second colleague. I mentioned locum staff earlier who might be breezing into a hospital for a week or two. Many more things go wrong where locum staff are on duty. I did not get to discuss in my initial submission the idea of a national expert panel comprised, for example, of the three masters and, perhaps, the clinical director of CUH. If they are not on duty, they usually have a deputy standing in. It would mean there were resources to fall back on where the need to discuss a complex case arose. One hopes it never happens, but if it did and colleagues in the hospital disagreed on the approach, there would be a need to obtain the opinion of some at the level of Dr. Coulter Smith or Dr. Mahony. We should consider strategies to deal with these types of scenario. In general in smaller units, the track record in terms of maternal morbidity has always been good.