Seán Fleming (Laois, Fianna Fail) | Oireachtas source

There was a debate in the Oireachtas on this recently. In his opening statement, Mr. Breslin said that in the years since these infections were discovered, a wide range of actions were taken, based on the recommendations of the Finlay and Lindsay tribunals, to ensure the safety of the blood supply. That encapsulates the problem. A problem arises and it is examined to make sure it does not reoccur but I would have liked wider lessons to have been learned from what happened with the blood supply. This is the undercurrent of today's meeting. The issue is dealt with but in a way that is totally divorced from everything else. I do not get the connection in this regard.

At a meeting with the HSE on 5 July this year, we asked a series of questions and we got a reply back dated 16 August 2018, which we read into the record today. The State Claims Agency was before us recently and we asked if it was possible that there were clinicians who were involved in multiple cases. The agency said that if a clinician was listed in legal proceedings, the agency wrote back to say the name of the clinician did not need to be given, on account of the fact that it was the enterprise which was defending the case. It seems the system is geared not to identify cases where learning is needed. The letter we received said the HSE asked for a note on the introduction of a mandatory system of retraining and supervision following legal settlements without admission of liability. It said there was no mandatory retraining and supervision following legal settlements without admission of liability, although retraining and supervision takes place. The letter stated that the HSE talks to the State Claims Agency and looks at the trends the agency has identified but it seems to me that this is not just acting after the horse has bolted - it is acting after the horse is dead and buried. The identification of these issues should be the role of the HSE, not the insurance company which is writing the cheque, which may be years after the event. The last line in the reply states that the office of Dr. Colm Henry, the interim chief clinical officer in the HSE, will have the ultimate responsibility for implementing any necessary retraining and supervision of medical practitioners. We are told that the State Claims Agency sends a report back to each of the institutions but these are landing all over the place. Whose job is it to identify these needs? The State Claims Agency is not picking up on them. The report states that cases can be brought to the medical council but that is not what we are talking about. That is for cases when somebody is judged not fit to be a doctor but that does not solve the problems where a practice is not up to scratch in some way.

This is why we are here. The medical negligence bill is increasing every year. The taxpayers have to pay it and that means less money for everything else. The figure has gone up every year for the past ten years and before that, but we did not get any indication that anyone was really worried about it. There is a demarcation between the HSE and the State Claims Agency. Once a case goes into the latter, the HSE is out of the picture. All it wants to know is what it owes at the end of the quarter. This demarcation does not help the learning process. The HSE should not have to learn anything from the State Claims Agency as the problems happened in the HSE to start with.

In his opening statement, Mr. Connaghan said the HSE had recently established a project team to develop a mechanism so that the learning from local reviews could be considered. He might give us details of that and send them on to us. He went on to say that, since 2013, the HSE had undertaken an annual review of completed incident reports. Are they published? Who is tasked with reducing medical negligence in the organisation when they come into work on a Monday morning? Without this being addressed, it will mean less for patients and lower budgets for the HSE as a whole.