Mr. Patrick Lynch:

On what we tried to illustrate in the report, we know already there are big areas of risk in terms of harm that happens in the health service. It is not always medical negligence. It is not down to a clinician who is negligent but to a whole range of factors. In the report, I tried to set out for members some of the big areas of harm we know that have happened. Really then, we should be way ahead of it in terms of prevention. I then have a particular interest in when incidents happen. We know that a lot of people go the legal route for a number of reasons. One is, in particular, that they do not feel they have got the answers to what went wrong. I have met a number of patients who have been harmed. Last week I met a number of mothers who had lost babies in Portiuncula and the committee is aware of the larger review.

Those three mothers are now involved in the improvement programme and are leading it. They told me that one of the reasons they went to court was that they did not get the information and were not told what had happened. They had very simple questions, namely, what happened, why did it happen and what had been done to fix it. They wanted to know that it was not going to happen to anyone else.

We work closely with the State Claims Agency, not only when it comes to claims but also in incident reporting. The national incident management system was established by the State Claims Agency but is owned by the public service. In the four years since its establishment, we have seen a 33% increase in the number of incidents reported. That is a good thing, although it may seem counter-intuitive, because any health system with a healthy patient safety culture will report incidents. That includes incidents where no harm has been caused at all, which may be negligible or which may have had no impact on the person involved. Good incident reporting leads to good learning at the outset. Any health system in the world encourages reporting because assuming that increased numbers are an indication of poorer safety takes from the culture of patient safety in hospitals, institutions or community services. That has been a big success. While the State Claims Agency can answer for itself, I think it would point to that as being very significant. It allows us to see the trends in incidents, whether at a local level in a hospital, community service or hospital group, or at national level. That is just one part of it.

Only 1% of the incidents reported are considered major or extreme. These are incidents that result in serious harm to people and, in some cases, people die as a result. We do not want to wait until a claim is lodged to get people to start looking at why it happened. With category 1 incidents, where that level of harm has occurred, there is a requirement to review them and understand what happened, not after two or three months but immediately. If another person coming in to that facility today will face a risk, that risk has to be sorted and the factors that led to the incident have to be identified. As I said in the paper, we have introduced an incident management framework. It is easy to talk about policy at national level but this framework provides a practical way for people to review incidents, get the learning and fix the problem there and then at local level. Some issues are more systemic but they may only be systemic in a hospital, rather than across a number of hospitals. All hospital groups and community healthcare organisations now have serious incident management teams and quality and patient safety committees that review that information. At national level, we also look at that data and where there are significant systemic issues, we may have a national initiative to deal with it or we may hold national learning events to get the message out across the system.

The question of open disclosure has been the subject of discussions here as well. That is fundamental to a caring healthcare system because it not only provides the person harmed with the information he or she is entitled to and should have immediately, but is a lever for services in itself. If we tell patients what happened to them, we are also expected to tell them what we are doing to fix it. I have tried to give a bit more detail.