Ms Róisín Molloy:

Mention was made of human error on the part of the local staff in the hospital. We know that, on the morning of 24 January, no staff actively went into work to cause harm to my child. We do know that human error occurs in all aspects of life.

The HSE has a department to oversee that. It acknowledges that human error occurs and that when it happens one has to investigate to prevent human error happening again.

With respect to what happened within the HSE, we had an investigation into Mark's death. The HSE's standard spin in the event of an incident happening is that the review is to establish why any failures occurred and, second, it is to identify the system's causes of these failures and the actions necessary to remedy these so as to prevent, or if prevention is impossible, to reduce the likelihood of a recurrence of such failures as far as is reasonably practicable. Mark's death in Portloaise hospital was not the first and neither was Joshua's death. This has been going on for decades. I can understand that human error can occur but at what stage does someone make a decision not to act? They had all the information there from the State Claims Agency, the doctors and the nurses. The public were trying to speak about this. I can point to the number of parents the other night who apologised and said, "We are sorry we did not keep going with it but we could not do it", and to the number of parents with children with disabilities who said, "We are sorry we could not force it; we could not fight the HSE because we are too busy caring for our child".

The issue here is that there must be collective responsibility. In terms of the medical staff that morning, there are the processes with respect to the Irish Medicines Board and An Bord Altranais. The HSE as an employer had a duty to discipline the staff who had deviated from their contracts or deviated from safe practice. We have already spoken about a doctor who changed his notes. He admitted he changed his notes. The investigation into Mark's death found that to be true. That doctor was never disciplined. No discipline procedures had started to be put in place in that hospital up until recently, up to about three weeks ago. Up to then nobody had been disciplined nor had a discipline process started.