Dr. Tony Holohan:

Senator Colm Burke's final point relates to the first point on the length of time it takes to get through some of the reviews. Frankly we share the Senator's concern and understand exactly what he is saying. Perhaps for reasons that might be understandable and particularly as it applies to maternity services as a result of some incidents that occurred - the Senator may remember some of the particular public criticism was for a failure to conduct or complete reviews in some cases - when more incidents occurred in the more recent past, there has been a determination to get the review process into place. In our view it is not always necessary to do the scale of review of the kind that is prescribed in each of these situations in every circumstance.

I might go back as to why one should do these reviews in the first instance. The most compelling reason to do a significant review when a patient safety incident has occurred and that speaks to the urgency and so on is if there is a reason to have a suspicion that there is a continuing concern about the safety of a service. The most important question to address is whether there is a risk attending to the patient who is coming tomorrow to use this service that needs to be addressed and there is an urgency around that. The next most important is if there has been a group of patients who have used the service in the recent past who might have been harmed and who need to be identified through a look-back and to be provided with some further service. We have had some examples of that. Obviously the individual patients who may or may not have been harmed will wish for a review of the circumstances of their own cases. That might not always be the most important reason for a review to be undertaken. We may have slipped into committing to doing too many of these large-scale independent reviews in circumstances where they are not always necessary when one thinks about the purpose to get to the learning and understanding of what has happened.

To return to the point we made earlier, if the disclosure of what is known at the start happens in the right way and is provided by the right people in order that trust and confidence is maintained on the part of patients and families, sometimes many of the questions patients have can be appropriately answered in that context without the need for recourse to independent processes and reviews. I am not at all saying we do not need independent reviews as part and parcel of our process.

The point Senator Burke is rightly identifying is that many obstetricians and other senior people are engaged in conducting large numbers of reviews from a limited capacity and then these reviews are not being done within the prescribed period, which for the HSE is a four-month period. I know the quality assurance and verification division in the HSE, which has responsibility, and HIQA are both doing important pieces of work in this situation. One in the HSE is to try to look at the different types of reviews that will be necessary in different setting. Sometimes, a quick analysis of what went wrong at a very early stage might be enough to address the question of continuing safety and does not need an elaborate and lengthy process that can take weeks or months to complete. One cannot have a process lasting weeks or months that leaves open the question of whether a service continues to be safe.

There is a question of horses for courses in the context of the type of incident and review. The HSE is now considering this very carefully. We are also working with HIQA, which is carrying out a review of national standards again. This is based on a recommendation that arose from the work we did in Portlaoise two years ago to examine developing national standards for different types of reviews in different settings. It is a matter of having the right type of review and not ending up with large numbers of busy front-line clinicians tied up with reviews that are not always of the right type in the circumstances. Addressing this will help to improve the circumstances that have been referred to.

The point made on the support of staff is a good one. The open disclosure policy and some of the other policies in the HSE will make this clear. There is an issue arising regarding the capacity of services in this regard and regarding the provision of the appropriate support. It is a matter of doing so in a way that recognises that the second victim is often the health care professional at the coalface. That individual might feel responsible. He or she might represent the final step in a chain of things that went wrong but may feel responsible. As was rightly said, he or she needs to be supported appropriately and to have his or her confidence rebuilt. Sometimes staff find themselves taking sick leave owing to stress. Alternatively, unsupported staff may continue to provide services without sufficient assistance and support while no longer in a position to do so as safely as possible. They may be seeing another patient later that day, the following day and so on. All these factors need to be considered as part of how we respond.

As a consequence of the additional moneys made available to the HSE for the provision of health services, we would like to see some of the resources dedicated to ensuring there is greater capacity at the front line for dealing with these matters. We can talk about all of these matters in terms of the right thing to do but if we do not invest in the development of front-line capacity and capability, there is little point in having numbers of staff such as ourselves in Hawkins House and Dr. Steevens' Hospital working on patient safety. It does not have to involve a large number of people but there must be staff whose day job is to ensure arrangements are in place to provide, where necessary, services to support staff members in the circumstances described. Meaningful investment has got to happen at the front line. We want to see some of the resources dedicated to developing capacity and capability at the front line.