Dr. Tom Ryan:

One question asked by the Senator was about the law of tort and causation. That issue is discussed at a point at which everything has failed because there has been a complete breakdown of trust and everybody has become adversarial. The law of tort was reformed in the United Kingdom in the early 1990s and in Australia in 2002. Whether a variation of care was coincidental with or had led directly to an adverse outcome is important because care is variable and should be individualised and personalised. It should not be regarded as poor or of a lesser standard just because there has been some minor variation. Oftentimes, one sees minor variations of care quoted in the media as if they were causative. That issue needs to be addressed if for no other reason than that it is unfair on the family, the doctors and the health care administration that there is unnecessary litigation and unnecessarily high awards. It is only logical that if a case goes to litigation to pursue a wrong, the wrong has to be proved and the causation determined, rather than inferred, implied, imputed or suggested. It must be proved that an action led directly to harm.

On the administration of health care systems, all centralised health care bureaucracies assume an animus of their own and tend to become depersonalised. Very often the people who head up centralised health care systems have little or no direct clinical contact with the patients at any stage during their careers. All one has to do is look at the NHS and the Mid Staffordshire report to see how attempts to micro-manage patient care from a bureaucratic office at some remove from the direct patient interface failed, compromised care and led to an adverse outcome. That brings us back to how the health care system is governed. It highlights the complete absence of clinical governance in the Irish health care system, with the sole exception of the voluntary maternity hospitals which have proved outstanding successes in providing excellent care for large numbers of women on a minimal budget. There is a problem with an excessively bureaucratic and isolated health care administration trying to run what is essentially a service system. That is my response to Senator Colm Burke's second question.

On the staffing issue, in high acuity areas we have to accept that there will be staff burnout. Everybody is not capable of dealing with stress seven days a week, 24 hours a day for five or ten years, at the end of which period most people will burn out. That is natural. Anybody with any empathy will suffer from symptoms of burnout after a period of prolonged stress, but we need empathetic staff on the front line to look after patients.

Many younger nurses come to intensive care, practise for five or ten years and then move to some other sphere in the health care system. They bring valuable knowledge and behaviours with them to the rest of the system. It is good that there is movement in the health care system. It is good for the the system and staff. There is nothing worse than forcing a nurse or a doctor to stay in place when he or she is burning out because he or she cannot deal with the stress. That is a natural part of a high acuity care system.

There is the question of whether medical staff were prepared for the Coroner's Court. In the past the Coroner's Court provided a great service for relatives. After somebody had died and if there was a question about the quality of care provided, we were always able to refer a case to the coroner. The coroner was a dispassionate, independent reviewer of the quality of care provided and the court was a great forum to attend. Unfortunately, however, the Coroner's Court has become adversarial, which it is not supposed to be. One ends up in the court testifying to the coroner but being cross-examined by a barrister. The point of the Coroner's Court is that there is a free exchange of information. One is there as the coroner's witness to provide him or her with help in determining the cause of death, but the presence of barristers for both sides completely inhibits this. The over-legalisation of the adjudication of what happens in patients who suffer adverse outcomes inhibits open disclosure. That is a problem.