Mr. Ollie Kelly:

With regard to what Róisín said, it is the belief of all the families that no one in the hospital intentionally went in to cause harm to anyone.

Deputy Mitchell O'Connor wanted to know what the people were doing in the hospital to improve matters. Frankly, they were doing nothing to improve the situation. What they should have been doing was learning from previous injuries and deaths that had occurred even prior to the deaths of baby Mark and baby Katelyn, but they failed to learn from anything.

The Deputy asked how that could be enforced. Accountability is the only way it can be enforced. Accountability will drive performance. If someone has to answer for their actions or, more importantly, their inaction, I believe that will help them to be more productive in their work.

Senator Burke raised the issue of under-staffing. A lot of the problem is under-staffing but it is also the quality of the staff. The doctor failed to read the CTG technology, and our little girl was in distress. The killing aspect of that is that the midwife did so, and through the inquest we found out that if they had acted on that, our little girl would be alive today. That is so hard to take in. The issue of the quality of the staff must be addressed when consultants, doctors and midwives are being hired in that area.

In our December meeting we also asked were staff being shadowed, and the training process that would follow. Another issue I have concerns consultants who work in the hospital for about a year and then move on. When they move on, do the issues the hospital had with them move with them? That is a major concern of mine. This consultant failed to read our little girl's CTG, and I am afraid he will move to another hospital. Doctors should not be allowed move on to other hospitals, as part of their learning process, until the hospital is confident that all the boxes have been ticked in terms of them being good enough to move on.

On that, like everyone else we had to go down the legal route to force the holding of an inquest because a doctor wrote on Amy's chart, and it remains on it today, that she left the hospital against medical advice. Under no circumstances would she do that. No mother in the world would walk out on their child and to put that down on paper is not right. Amy had to take the stand at an inquest to prove her innocence. I am sorry-----