Mr. Mark Molloy:

I thank the Irish Patients Association for inviting me to participate this morning.

Since the death of our son, Mark, in 2012, my wife, Róisín, and I have been active in seeking reform to the health service to attempt to implement change to many serious patient safety issues and obstacles that we encountered during this time. We would like to take the opportunity to welcome the many improvements and patient safety supports and initiatives that have been introduced in the past three years.

Unfortunately, our experience is of a system where great lengths will be pursued to contain adverse events by people at all levels and in various roles, who appear to have the fall-back position of complete impunity in the knowledge that while their actions may have catastrophic consequences for patients and a significant effect on front-line staff, there are no effective mechanisms in place to make them accountable for poor performance. While the State will continue to pick up the tab for the financial consequences of their actions, it is the lack of a statutory accountability framework that we believe is the single biggest impediment to health care reform in Ireland.

In the immediate aftermath of Mark’s death, we asked the management of the maternity unit why our son had died. We essentially sought open disclosure but were misled. Before Róisín left hospital seven days later, we asked the same question and were misled again. We know now that they had the answers at that time. We met the management of the hospital five weeks later and were once again not given the answers that they had. As each tier of HSE management did not give us the answers that were known to them about Mark’s death, we moved to a higher tier all the way to national director level, and were, as the then Minister for Health, Deputy Leo Varadkar said last year, lied to many times. Of course, as we now know, our experience was the same as that of many others.

I have read through the committee transcript of the meeting with the chief medical officer, Dr. Tony Holohan, and Dr. Kathleen MacLellan from the Department of Health and agree with the vast majority of their submission, particularly in relation to making open disclosure mandatory within the HSE for a certain level of adverse event and above. However, where we disagree is on whether open disclosure should be voluntary or statutory.

The management investigation that resulted from our last appearance before this committee in May 2015 is now more than one year overdue for completion, and estimates suggest it will be at least March 2017 before it is complete. This investigation is about non-disclosure by senior HSE management and this, in particular, is where we feel voluntary open disclosure in the health service collapses.

It is no secret that there is an apparent significant disconnect between HSE front-line staff and management, yet the enormity of the cultural shift that this voluntary initiative would require, like with any company, would demand top-down buy-in and full support if it were to be effective. How can we expect front-line staff to disclose openly and voluntarily when they witness management going to such lengths to contain incidents? Unfortunately, it simply will not happen.

While to err is human, self-preservation is one of our most basic instincts. We submit to the committee that the battle to encourage an open disclosure culture in the health service is long since lost at this stage and only through the introduction of statutorily based open disclosure and, most important, and this is such an important point, overseen by a broader legal accountability framework for all health care professionals in Ireland, can we have confidence that patients will be appropriately informed when things go wrong.

I thank the Chairman and members.