Dr. Alan Finan:

As Mr. Woods said, it is largely because we need to get the clinical expertise on board. As already identified, the system is understaffed with senior and expert clinicians as all of them are very busy and it can be very difficult for them to free up time to conduct these reviews, which take an enormous length of time and energy.

Deputy Ó Caoláin also made inquiries about compliance with our obstetrics and gynaecology programme guidelines. To date, the programme has issued approximately 40 clinical guidelines and in Cavan Monaghan Hospital, there is a clinical governance committee. Part of its role is to examine each of the guidelines as they issue and as they come off the production line to identify where we may have difficulty in achieving compliance with the guidelines. That system works very well and we are largely - in fact, in the majority of cases - compliant with all the national guidelines.

There are some areas with which we are struggling, namely, those relating to the necessity for networked care, an issue to which the Flory report also refers. Mr. Flory talks about networked care being particularly important in the case of high-risk pregnancies and foetal anomaly scanning. Hospitals the size of and, indeed, bigger than Cavan will always have difficulty with those areas and the only solution is networked care. I was very pleased that Mr. Flory emphasised that. The RCSI hospital group, whose three maternity units are Cavan Monaghan, Drogheda and the Rotunda, has done significant work in the past five or six years to progress networked care. We have developed a Dublin north east neonatal network which ensures that prematurely-born babies are delivered in the best location and at the right time. We have also made significant progress in developing a regional perinatal pathology service so that when babies unfortunately die, they get the expert perinatal post mortem that is required for their parents to be given clear, unambiguous and open information on the cause of the baby's death.

Foetal medicine is an area we have not adequately networked to date. However, a proposal is in place for this and there is a plan for staff recruitment in order to deliver it. We have had significant difficulty with that recruitment over the past 12 months and we have not been able to progress the plan for that reason. Deputy Ó Caoláin also asked about the practice development officer who has been appointed. A part-time practice development officer has been in place for a significant number of years and she has made an enormous contribution to the service and the quality of care provided. Recently, we appointed a full-time practice officer and she is a dedicated practice development officer for Cavan Monaghan Hospital who does not hold sessions in any other hospital.

Deputy Ó Caoláin also inquired about staff expansion. We have approval for four full-time consultant obstetricians in Cavan Monaghan Hospital. The only factual inaccuracy in Mr. Flory's report was to state that there was only one full-time person in place. Three full-time people are currently in post but we are having difficulty recruiting a locum for the fourth post, which is currently vacant. The Deputy is correct that three people are currently doing the work of four at consultant level. While we are doing our best to address that, there is a national difficulty in the recruitment of consultant obstetricians - it is not something unique to Cavan.

Mr. Woods spoke about midwifery staffing. The Birthrate Plus recommendation of 1:37 is based on a UK model published a number of years ago. A number of years ago, HSE north east, comprising Cavan and Drogheda maternity services, set a target ratio of one midwife for every 37 deliveries.

We reached that for a brief period a number of years ago, but it slipped as the financial climate deteriorated. In the Cavan-Monaghan situation, the staffing ratio slipped to 1:44 or perhaps 1:45. We are currently at 1:40, so the situation has improved over the last couple of years. Our target remains 1:37. As we have said, submissions have been made as part of the 2016 Estimates process to make sure we get to 1:37.

Deputy Ó Caoláin also asked about certain recommendations that are specific to reports that were completed previously. All of the recommendations coming from any reports are entered into a system with which maternity departments and clinical governance structures work constantly - week in, week out. There is a constant review of the report recommendations that are outstanding. Machinery is in place to make sure we are constantly aiming to implement all of the recommendations that are outstanding. That includes all reviews that have been done over the years.

I would say the same thing regarding the HIQA reports on Portlaoise and Galway. All HIQA recommendations are dealt with through the same internal departmental machinery. Anything that is not manageable internally is escalated to local management and, if necessary, to regional or national management. I believe we are making very significant progress in addressing all of the HIQA recommendations on maternity services.