Mr. Tony O'Brien:

Thank you. Any loss of a baby is always a tragedy and this is doubly so if the loss is avoidable. It is also true that any indefensible behaviours, lacking in basic human compassion, multiply that tragedy and cause unimaginable trauma and hardship. I want to make it clear that nobody is here today with a view to defending any of that.

As director general, I have made the organisation's and my personal position crystal clear on the central issue of compassion in care. I have communicated to all staff in the organisation that the required standard, particularly when things have gone wrong, is that we treat our patients, our clients and their families as we would wish to be treated ourselves and as we would wish our relatives to be treated. This message has been communicated to leave everyone in our wider health service in no doubt of the expected standard of behaviour.

In other jurisdictions where there have been failings in showing compassion such as in neighbouring countries, one of the approaches has been to seek to reinvigorate the capacity of leaders in the relevant disciplines to reinvigorate compassion in providing care. We will follow that example by inviting the Florence Nightingale Foundation which has been performing this function recently in the National Health Service in the United Kingdom to provide exactly that kind of enablement training for nursing, midwifery and interdisciplinary leaders throughout the health system and in all settings, not just acute services.

There are also very significant concerns about the way issues of risk were escalated and responded to within the health service. The HSE is instituting a formal disciplinary investigation into the issue of risk escalation and response and the issue of the absence of compassion in providing care. It will utilise external investigators who have never worked in the health service to carry out investigations in accordance with fair procedures and the disciplinary procedure in order that the requirement for accountability can be served.

In addition, there are concerns about governance, particularly in some of the smaller settings and their linkages with larger settings. As a result, we have commissioned Mr. David Flory, CBE, the outgoing chief executive of the Trust Development Authority of the NHS, to begin a process of examining these issues in some of our smaller services, in particular, and especially those involved in maternity services. That process will be extended to all services. This is not just about accountability. It is also about how we ensure these things do not recur and how we ensure services are improved to the greatest extent possible.

As the committee is aware, I was asked by the former Minister for Health, Deputy James Reilly, to be the first and I believe the last director general of the HSE. I took up the role on a designate basis in August 2012. At the time it was made clear to me by the then Minister that one of the reasons he had appointed me was that I had for some time been one of the chief critics of the way in which the HSE had been set up and the way it functioned, which was particularly centralised. It was my view then that the organisation was too big to function in its current construct. My experience of working in BreastCheck and CervicalCheck under the national cancer control programme led me to believe it was necessary to create different levels of governance in order to improve the way the whole system delivered. I, therefore, took the job on the specific basis that I was being asked to lead on that programme. In other words, I would not have taken the job in order to maintain the status quoin an organisational sense. In that context, the programme in which we are engaged of creating hospital groups, on the one hand, and community health organisations, on the other, is the central way in which we are improving the health service, not just for now but into the future, in order that decision making can take place, in the hospital sector in particular, within the context of governance constructs of arrangements of hospitals that make both geographical sense and bring management closer to the delivery of care and enable much of the networking and reorganisation of services to take place in a planned and coherent way. Similar issues arise in community health organisations, but I will not dwell on that aspect.

Contrary to what has been reported, the then national director of acute hospitals, Mr. Ian Carter, in response to the "Prime Time" programme on the Midland Regional Hospital in Portlaoise, immediately went to the hospital and engaged in a process which led to the appointment of a specific manager and a director of midwifery for the maternity services and the acceleration of a performance diagnostic. I also accelerated some of the things about which we had previously talked at this committee in terms of changing the structure of quality functions within the organisation and the relationship between these quality functions and the divisions with line responsibility for services.

In addition, after difficulties surrounding the competitions to fill the chief executive posts relating to those hospital groups, in the latter part of the second half of last year I took the decision to move the most effective talent we had available in order to ensure that life was breathed into the groups.

In that context, Dr. Susan O'Reilly, who is accompanying us today, was recently appointed as chief executive of the Dublin-Midlands hospitals group, the relevant group in this case. Dr. O'Reilly agreed to move from the national cancer control programme in order to take up her new role. The fact that I asked her to do so and that she accepted is a statement of our commitment to make the Dublin-Midlands hospitals group as effective as it possibly can be in addressing all of the concerns that exist.

As I have stated previously, we accept all of the recommendations contained in the HIQA report. It is true that we have concerns about some of the process issues relating to who did and did not have an opportunity to comment on the report. I will not dwell on that matter now but I will be happy to answer questions in respect of it if members wish me to do so. However, there are some continuing errors of fact, one of which I have referred to, namely, the notion that nobody at national level responded in any way to the concerns that emerged on foot of the "Prime Time" programme. I have explained to the committee what happened there. It is suggested in the report that it was the HSE which took the decision that Portlaoise should remain a model 3 hospital. As members are aware, the Government policy decision in this regard was announced at one of the committee's meetings in 2011.

The HIQA report also lacks any reflection of resource issues. In reference to resource issues I wish to make clear that these do not explain, excuse or minimise the importance of matters such as compassion and care. They do, however, have a significant impact on the way health services are delivered. The HSE is obliged to work within specified resources. During the years in question, those resources were diminishing significantly. I wish to provide the committee with a couple of examples of why resources are key in terms of quality and safety. As discussed last week - I believe it was Senator Crown who raised the matter - and in the context of international comparisons, we should not have 120 obstetricians, we should have 240. Making the shift in this regard would cost €24 million in a full year. Of course, such a shift could not be achieved in a full year. We now need to appoint directors of midwifery. Our decision to appoint one in Portlaoise was somewhat innovative but it has proved successful and is now recommended by HIQA. Appointing directors of midwifery to an additional 14 units would not be without resource implications.

Much is said about the HSE either being or not being a learning organisation. The term "learning" is important but many of the entities which have the characteristics of being learning organisations invest significantly in terms of time and effort in order to learn. If we were, for example, to release all members of our staff for just one day each year in order that they might focus on learning activities in the context of our care service, the cost of replacing them would be €9 million. If we wanted to release them from duties for a week, it would cost €63 million. Staff releases, training, etc., were among the first things that went when the financial emergency occurred. The HSE has not yet recovered to the position whereby it has the financial resources available to allow it to reinstate them. There would also be a significant cost involved if we were to bring all of our emergency departments, EDs, to a point where they would have full 24-7 consultant cover.

While the points I am making are not in any way being put forward as excuses in the context of issues relating to compassion, they are an important part of the overall matrix when it comes to quality and safety within the service.

We had a discussion with HIQA about that, mostly because its terms of reference require it, under the legislation, to take into account both Government policy and the resources available to the executive, which it elected not to do.

In terms of the future I am absolutely convinced that the course we set out on two and a half years ago to create hospital groups, to change the way the organisation was structured and to remove the regional layer is a journey that, when complete, will have an enormous impact on the quality of the services we provide, on the way we relate to our staff and on almost every aspect of the delivery of health care in Ireland. That is a journey that I intend to complete for those reasons.

It is often said, and I agree, that this report is a watershed. I have an additional reason for saying this. It is because it has a huge impact, and will have a huge impact into the future, on the interplay between Government policy and funding and on the role the HSE must play in interpreting those issues when it decides how services will be provided. This is written fairly large in the report and represents a variation on previous practice. Given that the report has been issued, it has a fundamental impact on how the health service will have to operate in the future.