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

We welcome Mr. O'Brien again. We know there are restrictions on what an Oireachtas committee can say and on discussing issues in great detail, which arose as a result of the Abbeylara judgment, so we will keep our comments generic. Mr. O'Brien and his colleagues are the collective leadership of the HSE and have responsibility for the HSE.

In our detailed discussion this morning, Ms Róisín Molloy spoke of her experience and that of her husband. We also heard from Ollie Kelly and Amy Delahunt and from Patient Focus on the issues in Portlaoise. In her closing testimony, Ms Molloy said: "We were treated with disdain. They hated us." It was powerful because she had outlined the efforts she had made as an individual from the day her baby was born in Portlaoise on 24 January 2012, culminating in a continual effort to get to the truth of what happened and to ensure it would not happen to others. We also heard that many people had told Ms Róisín Molloy during her interaction with the HSE that this had not happened before and would not happen again. Unfortunately, just last Wednesday, the Minister heard many testimonies from many people that things did happen before, such as a lack of compassion in dealing with people who had issues relating to their health care and when they made subsequent efforts to find out the truth of what happened. It has been happening for some time, Mr. O'Brien, and it is an issue we would like to be addressed in a meaningful way.

Mr. O'Brien spoke about a watershed moment, and HIQA last week said this was a watershed report. It is a very detailed report and makes for harrowing reading in parts. It is not very complimentary of the HSE in general. Mr. O'Brien said he takes issue with some of the findings in the report but not with the recommendations, which I assume he accepts. I will go through some of the areas referred to in the report.

On page five there is reference to weak oversight and inaction. On page eight it states there was "no evidence that the HSE nationally was proactively exercising meaningful oversight of the hospital and the inherent risks there". On page 18 it states there was "an ongoing failure on the part of the HSE to evaluate the services provided at Portlaoise Hospital against the risks and recommendations identified in previous local and national reviews and investigations conducted by the Authority and HSE". It further states: "Sufficient action was not taken by the HSE at national, regional or local level to address these issues." On page 46 it states: "Whatever the rationale for any decisions underpinning the model of care to be delivered at Portlaoise Hospital, it would be expected that the HSE would ensure that the hospital was safely structured and resourced to provide the care it was delivering." I would appreciate Mr. O'Brien's response to that comment in the report. He made reference to the fact that it was a policy decision that Portlaoise was retained as a model 3 hospital. He said that was a political decision announced here at the health committee. At what stage does policy override patient safety? If a decision is made at policy level for something to be done and the HSE is charged with responsibility for implementing that policy but if patient safety is an issue, at what stage does the HSE say that it cannot deliver on that policy? I would like some clarity on that issue also.

The report states: "In 2013, [HIQA] recommended that the Department of Health and the HSE would work together to conduct a review of the national maternity services and develop and implement a National Maternity Services Strategy." It further states: "At the time of finalising this report 19 months since the Authority published this recommendation, a national maternity strategy has not been developed or significantly progressed. The Authority considers the delay in developing and publishing a national maternity strategy unacceptable." I know that a review is currently being carried out, as announced on foot of the draft report being presented to the Minister.

It seems at every level that the efforts by the families - we must always centre this back on the families - to try to get to the truth of what happened in their circumstances were stonewalled and barriers were put in place. I do not say that lightly; I say that because I genuinely believe the families' testimony to us and that other families I have met and listened to felt that at every level the HSE was very slow in its efforts to come forward with information. We have some testimony from families, particularly from Amy, Ollie, Mark and Róisín, who said they were basically informed that they could get the information through a freedom of information request. We know there is not yet a policy of open disclosure in the HSE services across the country but at the very least one would think there would be an inherent compassion in an organisation like the HSE to help the families get through their grief, but it seems right through all this that the opposite was the case.

I find it hard to accept, having read through the full report, that patient safety was not on the agenda, as stated in the report. Patient safety was almost never on the agenda in terms of discussions at national level even though, by any stretch of the imagination, everybody who was in a senior management position in the HSE would have or should have known at that stage that there were major concerns in Portlaoise hospital and that they were being expressed to senior management at both local, regional and national level. The report by HIQA and the statements by the families indicate there was a very slow response or, one could say, no response in many cases to the alarm bells that were ringing. We talk about a systems failure and the fact that red flags were not being raised but, as I said to Mr. O'Brien last week when we were discussing other issues, alarm bells were sounding off everywhere at every level. The State Claims Agency was writing in this respect, the INMO was lobbying for extra resources and patients who had terrible experiences and tragic outcomes were consistently contacting the HSE but almost to a person they were consistently being denied an opportunity to fully find out what happened.

If the families who had tragic experiences in Portlaoise hospital had been embraced by local, regional and senior management, happier outcomes could have come about for those who interacted with the health services at a later stage.

Mr. O'Brien referred to a watershed. In 2008 there was a report on the provision of care of Rebecca O'Malley. Again in 2008, there was a report on the investigation into the provision of health services to Mrs. A by University Hospital Galway. In 2009 there was a report on the investigation into the quality and safety of services in the Mid-Western Regional Hospital, which is known as the Ennis report. In 2010, there was another report on Mallow hospital, referred to in this report as Mallow. In 2012, there was a report on the investigation into the quality, safety and governance of the care provided by Adelaide and Meath Hospital, Dublin incorporating the National Children's Hospital, and in 2013, there was a report on the care and treatment provided to the late Savita Halappanavar.

The constant difficulty we have is that these HIQA investigation reports made a number of findings and recommendations for the relevant hospitals, and the Health Service Executive, HSE, nationally, which should have been used by all health care services as a learning tool to inform and improve practice and drive service quality and safety.