Mr. Patrick Lynch:

A couple of things arise in this context. As I am conscious that there are often many new faces from the HSE around the table, I might help the committee by briefly explaining my role. As part of its service plan for this year, the HSE has introduced a new accountability framework, part of which involves a restructuring of our quality and patient safety function at a national level. My role has been established this year with a slightly more independent input in the organisation in terms of looking at quality and safety and seeking to provide assurance through audit. That is one of the reasons the Flory reports were commissioned. When people come to our health services, they expect at the very minimum that they will be safe, that they will be treated with compassion and that we will care for them when they cross our doors.

I know that the committee had a considerable discussion on adverse events at a recent meeting. I suppose it is something we really need to have a greater focus on. It has been our experience, and certainly my experience, that when people experience something going wrong in the health service, they look for a few things. First, they want to ensure the services are as safe as possible so that what happened does not happen again. They certainly do not want it to happen to somebody else. Second, they want answers for themselves. This year, we have introduced a new system whereby we record what we call serious reportable events. There is a mandatory requirement to report on all of these events when they occur, with a requirement now across the organisation that they be investigated within 120 days. From the August performance report, we will now be reporting on the number of serious reportable events for each month and we will be tracking the progress being made with the implementation of that target for investigation and review timeframes. I have to say we are nowhere near that yet, but that is the intention.

Following on from what Dr. Finan said, there is a struggle at times with professional staff, particularly busy clinicians, being made available. We work closely with the forum of postgraduate training bodies to identify clinicians. The forum is enormously helpful in that regard. Part of the 2016 programme will involve determining how we can do this more effectively, particularly in certain areas. We know there are groupings of events at certain hospitals, including Portiuncula Hospital. We need to do that more efficiently, so that is a programme of work.

Reference has been made to complaints. The ombudsman has met the committee. Members will be aware that a report on the complaints management system in the acute hospitals sector was produced and threw up a number of issues. My office is working very closely with the ombudsman. The report in question is now, in effect, the implementation plan for the development of our complaints management system, which will now be led from my office. The system in question will apply across hospital and community services. For the first time, we now have people at national level in each of the service divisions within the hospital groups and the community health care organisations who are responsible for complaints management in their service areas. We recently published on our website a full list of complaints officers across all our services across the country. There is a significant amount of additional work to be done there. In any industry, complaints are the lifeblood of understanding what is going on in the service. If we are not in a position to invite, hear and respond to concerns as they arise, we will never develop a greater focus on quality.

I am aware that at the last meeting there was some discussion about the sharing of data with the State Claims Agency. As a result of the way the legislation was set up, State claims relate to individual hospitals. We now have agreement from most of the hospitals that the relevant data will be released. This means we will soon be in a position, for the first time, to have intelligence at national level and hospital group level around what is actually going wrong, where it is going wrong and what needs to be done to address it.