Bernard Durkan (Kildare North, Fine Gael) | Oireachtas source

A few things come to mind. As the Minister and the director general know, this is not personal. I have often repeated - in fact, I have said continuously - that I am not happy with the structures in place within the HSE in general, but that is not the fault of the staff. The structures in place are not at all convincing in terms of the chain of command. There is no chain of command, as this incident proves. I presume the National Cancer Registry should be part of the chain of command and report to someone somewhere along the line. Surely the reporting should continue along the line to someone at a senior level. Who are the people at senior level to whom those reporting should report? Why did they not report? If the information was available to them at an earlier stage, why did they not convey it? Furthermore, I still believe - the Minister knows this well from previous debates we have had here - that whatever changes are made as a result of what has happened should lead to the creation of a structure that will be accountable and seamless from top to bottom in order that information will flow immediately in both directions and in order that whoever is the director general or the Minister will be au faitwith what is happening and required on the ground. In another context I remember a chief executive who had a sign on his desk that read, "I am part of your team. If someone makes a mistake, tell me. If someone deliberately drops me in it, start running". He conveyed a message to all and sundry about the way the ship was to be run. That is what we are missing. I am not blaming anyone personally, but it is a fact of life that the current structure is unworkable. It operates in watertight compartments. It is the silo mentality. As long as it does not change, women and men who need health services of one kind or another will be put at risk.