Mr. Tony O'Brien:

I mean from the whole report. The draft comprised only approximately 106 pages, given that it did not include the appendices, recommendations or executive summary. In the ordinary course, anybody compiling a report would seek to go back with a draft to people who had been interviewed or who had been involved in matters to which it related. Some individuals received a sentence, three lines or a paragraph, and others received nothing. Based on communications from staff elsewhere in the system, a number of nurses, midwives and other medical personnel had taken part in workshops, interviews and so on, but had received no part of the document to review, despite having requested it. This was my first area of concern.

I ended up writing to various HIQA officials on five occasions seeking some basic information on exactly what was required of me and asking who else had been provided with sections so that I did not need to go through the process. There were issues that did not seem to have an evidence base and for which I asked to see the evidence base. These letters have been published and there is no mystery about them. The central issue was information and a meeting for the purpose of clarifying what was requested of me. If this were a report by any other regulator, such as the Mental Health Commission, an Coimisinéir Teanga or the Comptroller and Auditor General, these matters would not have been considered problematic. Such meetings and additional information would have been provided as part of the normal course.

Given that this particular regulator refused to engage in any way whatsoever, I indicated that I would have to consider seeking intervention, not to prevent the conclusion of the report but to enable me to do what I was being asked to do, namely to make a submission in a representative capacity on behalf of a wide range of people who were not being given the opportunity. I wrote to HIQA to indicate that if I could not get progress, a judicial review would be under consideration. I simultaneously wrote to the Department of Health asking it to intervene, which it did. As a result, we had a meeting at which additional information was provided, the timetable for the provision of a response was agreed, which needed to be extended due to the amount of time that had elapsed, and we made the submission.

Regarding the changes that were made, I am happy to indicate the matters that were not features of the report but which now are. One of these is the recognition that the national maternity strategy which, as per the Chief Medical Officer's report, was to be published by December 2014, was a matter within the determination of the Department of Health rather than the HSE. In the initial draft there was a critical line that said the HSE was at fault for not having published a White Paper. As members will be aware, a body such as the HSE has no role in the publication of a White Paper.

Absent from the report was recognition of the publication of a number of national guidelines by the national clinical effectiveness committee and the HSE's clinical programmes including the Irish maternity early warning score, I-MEWS, Communication (Clinical Handover) in Maternity Services, Sepsis Management, The Management of Second Trimester Miscarriage, Guidelines for the Critically Ill Woman in Obstetrics, Resuscitation for the Pregnant Woman, The Diagnosis and Management of Ectopic Pregnancy, and Bacterial Infections Specific to Pregnancy. Also absent was acknowledgement that all hospital were implementing the national early warning score, NEWS, and I-MEWS and that, on average, between 70% and 90% of staff had received full training on their use. The report now acknowledges that significant progress has been made on the implementation of recommendations from the Chief Medical Officer's report relating to the reporting and management of serious untoward incidents, also known as serious reportable events. These include setting up a serious reportable event governance group chaired by the then HSE director of quality and patient safety; publishing a safety incident management policy, which sets out the HSE's policy for managing safety incidents; publishing a list of serious reportable events and an implementation guidance document; issuing a directive to all providers to require them to notify serous reportable events to the national director responsible for their services; and educating staff and training them in respect of safety incident management.

The authority also confirmed that the HSE actively progressed the implementation of recommendations made in the Ennis and Mallow reports in small hospitals.

The authority recognised that it was not the HSE that determined the services to be supplied by any hospital but that it was a matter of Government policy. That is stated on page 46. The authority also amended some of its findings entirely and others significantly owing to various more minor issues.

Are there outstanding concerns? I have referenced the fact that a reader of the report and the media reached the conclusion based on the report that nobody in seniority had responded to the "Prime Time" programme by going to Portlaoise or taking any step. In my opening statement I covered the fact that the then national director had spent considerable time in and that the regional director of performance integration effectively had taken over the hospital on a direct basis pending the appointment of the various other post holders I mentioned in my statement. It would be reasonable for people to look at us completely sideways and aghast if they believed nobody at national level had intervened, but it is completely untrue.

Deputy Billy Kelleher has made reference to the other suggestion about which I have particular concern in this regard, that is, that the issue of patient quality and safety more generally is not on the agenda at senior levels of the HSE. We provided for them a detailed submission which comprehensively refuted that suggestion. As members will be aware, in 2013, with effect from 27 July, the board of the HSE was abolished and replaced by a directorate. To be a member of the directorate, one must first be a national director of the HSE. It is an unusual and transitional governance arrangement, but the effect is that the directorate is a subset of a wider leadership team. The reserved functions of the directorate are prescribed in legislation. The directorate meets to perform these reserved functions. It also meets collectively as part of the leadership team with all of the other relevant national directors. At the time, the director of quality and safety was not a member of the directorate, while other key people whom one would want for any discussion such as the national director of human resources and so on were not members of the directorate. The directorate chose, therefore, to transact the bulk of its business, that is, its non-reserved business, as a matter of generality as part of the leadership team. The agendas for that team include quality and patient safety and they were supplied to HIQA.