Dr. Tony Holohan:

I ask my colleague, Dr. MacLellan, to assist me in responding, in particular to the question on what we have learned from other jurisdictions. We do have an amount of experience in terms of that matter.

In respect of the point made about apologies coming too late and having to be dragged out of people, we completely agree with the Deputy. This is a consequence of the culture that exists and is not an easy thing to change. We have direct experience of this matter. As the Deputy may know, both Dr. MacLellan and I were directly involved in carrying out the examination of what happened in Portlaoise when the case of four deaths of normally formed enfants occurred in the early part of 2014. It was clear to us, and by no means confined to Portlaoise in our view, that the way in which the patients were treated was nothing short of unacceptable. Far from failing to provide open disclosure in that context, there was an active, and in many respects, a determination almost not to reveal full and clear facts to patients who clearly were entitled to have them. We are a long way away from addressing the context in which such cases arise. Unfortunately, there have been others cases which involved the kind of response that was far from what we would need to see.

Part of the picture is a perceived risk. Sometimes clinicians, and I do not just say doctors but often doctors, perceive themselves to be putting themselves at risk by being forthright and clear about what happened in a particular context and perhaps apologise. Part of our strategy, as well as being clear through open disclosure policies, about what constitutes good open disclosure and what the expectations are, is to try to remove some of those things that we know are barriers to that happening. Our strong sense is that when something goes wrong in the care of an individual patient - as I say, it does happen - we can work to reduce such occurrences. However, when it does happen there is really only one good opportunity to try to get things right and that is the point of first interaction with the patient, which is often with senior medical and nursing staff. If trust and confidence breaks down at that point and there is not full disclosure, and there is then a clear attempt to try to ensure that the trust and confidence of that patient is maintained thereafter then no amount of activity after the fact will make up for what happened at the outset. Very often, investigations and other responses from the patient's point of view are incapable of fully compensating for what happened. He or she is certainly unable to get back into a situation where his or her trust and confidence in the service that he or she may often have to continue to use, is capable of being restored.

A lot of our effort is about trying to support through training and standards, on the one hand, and then also looking at the legal environment and the perceived risk that people believe themselves to be at, to ensure that they engage properly with patients. Also, to ensure that they do not circle the wagons and stop interacting and communicating with patients and families in those circumstances. In many respects, it is a time when patients and families need them the most. That is at the core of many of the significant patient safety incidents that we have seen in this jurisdiction. It is at the core of many of the significant patient safety incidents that have been written about extensively in the literature. Services and service providers stop communicating, stop being full and open and stop being truthful about what has happened. As a result, trust and confidence breaks down on the part of patients. No amount of compensatory actions after that fact are capable of redressing those deficiencies.

In terms of the point made about a lack of accountability by senior management, the Deputy made a good point that we need to ensure it is not just a matter that the quality of care patients receive is only seen as a matter for the doctors, nurses and other health professionals providing a service. In a situation where an adverse event occurs, where a patient has been harmed and where there may be changes in the treatment provided to him or her, their might be life altering outcomes for those patients as a consequence. All of that interaction will need to happen with clinicians who are capable of explaining and interpreting that for those patients and supporting and continuing the provision of care. As the Deputy has said, behind that there needs to be accountability when it comes to the management of the system.

Members will be aware of the framework for accountability as it has been much talked about.

Much of the emphasis in public discourse has been around the financial components of the framework. There are four elements to the framework, one of which includes patient safety and quality. We must have a situation whereby senior managers and policy-makers in the system accept accountability for the environment in which clinical care happens because, as Deputy Kelleher rightly said, it is not just clinical service, there is an interaction between a variety of different factors that increases or reduces the risk of an incident occurring. Some of those factors will not be in the control of individual doctors or nurses. Often it is not a case of incompetence or even poor performance. Sometimes adverse events occur when things go wrong but sometimes they occur when things have not gone wrong. Adverse outcomes are part of the imperfections in the science but there clearly needs to be accountability. We want to see more in the way of specific provisions in those systems so that there is more measurement and reporting, more transparency in terms of quality of care and specific measures that speak to the nature of the quality and safety of service put in place if they are deemed to be important parts of the provision of service. We see health service management right up to the top of the HSE accepting, and being asked to accept, accountability for performance across the so-called balanced scorecard, which does not just look at money. It looks at money, access, HR and patient safety and quality. We do not want to end up pursuing a high standard of accountability, for example, in regard to finance, while inadvertently compromising issues in regard to safety and quality. We must have a balanced approach to all things.

In the jargon, and I do not want to slip into using jargon, people talk about clinical governance. In essence clinical governance means there is corporate accountability for the quality and safety of services delivered to patients. It cannot be seen, as might have been the case heretofore, and not just in this country, by the senior leaders in the health care environment that quality and safety of services are really matters for the doctors and nurses and are nothing to do with the people in the boardrooms and offices. That is old thinking. The international community, as we do, understands patient safety very well and we need to ensure that accountability reaches all the way into the boardrooms and the senior management rooms of the operation and delivery of the service.

I will ask my colleague, Dr. Kathleen MacLellan, to give a brief account of the systematic look we have had at other countries and what we have learned from that.