Alan Kelly (Tipperary, Labour) | Oireachtas source

The same seven minutes the Chair had. Sorry, that was just a bit of a joke. I welcome the witnesses and thank them for their work. I was embarrassed that they felt they needed to apologise about timelines in the beginning. Their work is excellent. It is one of the best reports we have seen in these Houses in my time, especially one delivered in a short time. I have many questions but will prioritise them. Some of the questions relate to the report and I have discussed that already. I will not go over them because the witnesses have been quite accessible. I have questions about the future and where we need to go.

The most important thing related to the report is that the recommendations are implemented as soon as possible. We should work from that baseline and take that as our priority. Everything else is subsequent to that. It should be all about protecting this generation and future generations. That is what the women who are affected, their families and patient advocates have as a priority too. I have spoken to them numerous times.

I want to drill into the terms of reference the witnesses were given, which are partly our fault as legislators. There is a lot of commentary on this issue.

Journalists and politicians need to be careful sometimes about the language they use because language is very important here. Sometimes there has been a use of language which was not necessarily accurate. Dr. Scally was not asked as part of the terms of reference to go in and investigate what happened in the 221 cases, as regards the laboratories themselves. I believe that is something we probably left out. I am not sure if he would have been able to do that anyway from a timeline point of view, but that did not happen. I am aware there is an ongoing review by the Royal College of Obstetricians and Gynaecologists, RCOG, but let us be clear, the investigation of the laboratories and the 221 cases, or whatever the number is - I think it is slightly more - was not part of remit.

In particular when we outsource such work, and also when we insource, contracts are in place and reviews are built in as part of that. There would be built-in reviews as part of these contracts using organisations such as HIQA. When the HSE became aware of issues, why did it not drill down into what was happening and investigate each of the cases? Why did it not happen? Will it ever happen? Will we ever find out what happened in each individual case? Will we drill into the detail of each individual case as regards the people who were looking at the slides, the fact that they were misread and that the information was not brought to the attention of management? Why did that not happen? According to the contracts which I have looked at, there were meant to be regular inspections but they did not happen. There were five inspections over eight years. Issues did arise in the inspections but they were not followed up. That was a failure. Why did that not happen?

I am sorry for asking all these questions. No inspection has been carried out since 2014. Is that acceptable? On the errors, probably the most important finding was that the laboratories appear to be statistically in line with international norms in their findings, but how do we know that is corroborated in the 221 cases by follow-up investigations in the individual cases? Does Dr. Scally follow what I am saying?