Ms Sheila O'Connor:

I will be brief. I think HIQA's report reflects exactly what happened in the Midland Regional Hospital, Portlaoise, but I will go a great deal further and say it probably reflects what happens in most hospitals in the country. I was horrified at and shocked by the reaction of the HSE a couple of months back to the imminent publication of HIQA's report and its denials of patient stories, as if they were fabrications. They were the same stories we had heard morning, noon and night during the course of the past two years. For the HSE to imply that the parents were wrong, that they were over-emotional and that there was a lack of due process is an absurdity. I really find it very difficult to take that on board.

The structures in the hospital clearly had not worked. What both families are saying about the complaints process is correct. When Mr. Mark Molly said he and Róisín Molloy had got a good review, they were correct. In fact, they got a spectacular review in comparison to any other patient that we in Patient Focus had ever dealt with. That was as a result of their tenacity and courage in standing up for their baby. In our opinion, it is undoubtedly true and I do not think anybody who knows anything about this can contradict that view. It is totally true. Ms Róisín Molloy gave a description of being considered a crazy mother. If we had one pound for every time we listened to a patient tell us that they were considered to be "a crazy person, that I am this and that", Patient Focus would have a great deal of money. That is the standard reaction to bad events in a great many hospitals in the health care system. Sad to say, but it is true that the issue of safety is not taken seriously. It is a Cinderella process within the HSE. It is not true to say HSE personnel do not listen. They certainly do listen and hear, but they do not take on board, emotionally or psychologically, what is said. It is a self-defence mechanism that clicks in when they hear about terrible stories and they feel at some level that they may be or held personally responsible. They want to be able to go home and sleep at night; therefore, they do not take it on board.

On what should happen in terms of accountability, I have concerns, as one frequently finds, that the good people leave. I was very worried about the incentivised retirement scheme for HSE employees a number of years ago. It is true to say, from the experience of those involved in Patient Focus, that the best people, the ones who had supported Patient Focus, walked out the door. They have got jobs in other areas since, which is a terrible loss to the system. The people most interested in patient safety took a hike. I do not know if my colleague, Ms Molloy, agrees with me, but I think that is true. They were quality people who could go elsewhere.

People in the HSE have no power and the description of the complaints process brings this into stark relief. The complaints process is about following due process for staff; it is not really about finding out what happened. That is the reason it takes so long. People get up on their horse, go to the trade union, professional bodies or lawyers, or they go sick. Every single possible strategy an individual can use to delay things is used.

This should be about finding answers for people who have had dreadful experiences, but it is not. That is the reason external reviews should be conducted and answers provided quickly for those who have had bad experiences. That is not too much to ask.

The health care system is spectacularly bad at dealing with bad events. I do not know what that comes from, but it is part of our culture and history. It is part of the major power structures still within society and the general population are perhaps afraid of them. In the health care system there is a dependency relationship between the patient and the professional and the one thing people do not want to take on board is the fact that perhaps they were let down by their professional. It is incredibly difficult to take this on board. I do not wear hats, but if I had one, I would certainly take it off to the families here. The Molloys jumped on board immediately and sussed out exactly what had happened. Emotionally, it is incredibly difficult to do that and remain intact psychologically.

There were a few other questions. Deputy Caoimhghín Ó Caoláin and others raised the issue of a patient safety agency. Patient Focus has always been in favour of having a statutory patient agency authority. I was on the board of HIQA for a number of years and during that time I grew to have huge admiration for the former CEO. The other day I saw Mr. Phelim Quinn on television at the launch of the report and, to be honest, I thought to myself, "I would not like to get on the wrong side of that man." That was my gut feeling in terms of his body language and demeanour. That is my personal view which I have not discussed with anybody in Patient Focus. Mr. Quinn means business in bringing about a cultural and mindset change in the health care system in Ireland.

Things are much worse in private hospitals.