Colm Burke (Fine Gael) | Oireachtas source

I thank the witnesses for their presentations. Open disclosure is very important. I am a little concerned about the capacity to deal with it within the HSE and will give one or two examples. First, an adverse event occurred and it was agreed by all of the medical staff in the particular hospital that there should be an independent review to make sure full information was given to the family. The hospital identified an independent person to carry out a review who was outside of the HSE group but still within the HSE. The decision was overruled by a person in administration in the HSE and 18 months later, the independent review has not been carried out. Surely, this should not arise.

While I know it is not tied into Dr. Holohan's area, a second issue that is causing a great many problems for families, especially where somebody has died, is that there is no obligation on coroners to hold an inquest within a period of time. My understanding is there is no provision in current legislation that a coroner must hold an inquest. If there is a delay, there is the immediate presumption by the family that something is being covered up. That needs to be addressed immediately.

Third, on the question of support for staff where there is an adverse event, I am not at all clear there is support for hospital staff, be they nurses, junior doctors or even administrators, because when there is an adverse event in a hospital, it affects everyone working in the hospital. What is being developed to provide that support? I am aware of a number of incidents, in which no support of any description was given to staff and as a result, the number of staff members on sick leave increased because they had been adversely affected. What are we doing in regard to setting up support mechanisms for staff?

Nearly every week we have a situation where there is some reporting of an adverse event in the maternity services. The big problem with independent reviews is that because we have a shortage of medical personnel in maternity services - in that the number of consultants is lower than in other jurisdictions - we have a shortage of personnel to carry out independent reviews from outside the HSE group and it falls to a consultant in another HSE group to carry out the review. As a result the process of review is very slow. Maternity cases are significant and all of the relevant information must be provided in the fastest possible time. What mechanism is the Department and the HSE considering to deal with that area in particular?