John Crown (Independent) | Oireachtas source

I did not know we had spokespeople. I am sorry. I will finish very quickly. In the case of Neary, responsibility was put onto the individuals who carried out the terrible, awful practice but there was something wrong with a system which allowed somebody to act, effectively single handedly, way beyond their competence and their surgical skills in a hospital which did not have an intensive care unit, a blood bank or any of the things it needed. It did not have appropriate levels of peer review which would have found that there was something wrong with this man and that he needed to be stopped. Not only does the responsibility devolve on him, it devolves on the system.

The case of Savita Halappanavar is telling. When that awful tragedy occurred, two and a half years ago, I pointed out that, from what I had read about it, the hospital in Galway did not sound like an optimally safe place to have a child. The problems were not unique to Galway but it was grotesquely understaffed. It did not have the kind of staffing one would expect in a modern obstetric service, one that hilariously boasts of having the best outcomes in the world when it manifestly does not. These problems were pointed out years ago but what is being done about them?

We can do a number of things. We definitely need a better complaints procedure and an appropriate culture but we also need to fix the system. In the Titanicanalogy, we need not just a better inspector of lifeboats and not just a better complaints procedure for those who lost someone in the disaster but enough people on the bridge to make sure the ship does not hit the iceberg in the first place. Then one needs to have enough lifeboats in place. Some very hard questions will be asked this afternoon.

I give my sympathies to the witnesses. I cannot imagine what they have gone through and I commend their bravery for coming here today.