Mary Harney (Dublin Mid West, Progressive Democrats)

The Lourdes Hospital inquiry is a body blow to us all. It is painful to read, it is hard to believe and it is shameful and distressing. It is more akin to a novel set in the dark early part of the last century than the story of the enlightened, successful, confident country we live in.

To the women who were the victims, this report is their story. It is the story of how the health system failed them and how it continued to fail them. It is the story of women robbed of their ability to bear children. For 44 women it is the story of a deliberate attempt to compound that failure by denying them justice.

For centuries, the maxim "first, do no harm" has been the very starting point of medical ethics. Yet, over many years at this hospital, this first basic ethical test was violated, with tragic consequences. I want to thank Patient Focus, the group which represents many of the former patients of Dr. Neary, for its co-operation with the inquiry which must have been personally very difficult. Once again I express my sincere regret to these women and their families for the pain and the loss inflicted on them.

Judge Maureen Harding Clark and her team have conveyed this difficult story through this powerful report. Perhaps the greatest compliment to the achievements of the inquiry team is the universal comment that this is a fair report. I thank all of the team for the great service it has done. In the future this report will be seen as a catalyst for reform in the health services, an essential read for every student of medicine. Since the publication of the Our Lady of Lourdes Hospital inquiry report last week, I have met Patient Focus, the medical board and management team of the hospital, the Medical Council and representatives from the National Hospitals Office of the Health Service Executive. It is fair to say that this report has had a profound effect on everyone. There is a sense of hurt, shock, outrage and regret. We need to harness these emotions in a productive and positive way. We will take the findings of the Our Lady of Lourdes hospital inquiry and implement them one by one in a manner that bears testament to the private and public outrage.

To do this we need the support and co-operation of all players in the health system. The facts revealed by the report are stark. An isolated hospital or isolated practitioner breeds ignorance and puts lives at risk. We have seen how these backward practices ruined lives in Drogheda. There must be a process of outcome review by peers. Information must not only be available but must be analysed, questioned, compared and reviewed.

To this end I am pleased to announce the setting up of the national perinatal epidemiology centre in Cork University Hospital which will be up and running in the autumn of this year. The centre will cost €630,000 in a full year to staff. This means that every time a mother gives birth, the important interventions, good outcomes and complications will be recorded and analysed at a national specialist centre. Unusual trends will be easily and quickly observed and, most importantly, acted on. The centre has been designed based on models from Australia and its immediate priorities are to devise a single identical maternity chart for every maternity hospital in the country. This is the first very important step in re-establishing trust and ensuring that services to mothers and their babies born here are based on the best possible research.

One of the issues I discussed last week with Patient Focus was redress for the women involved. As a first step, the Government yesterday agreed that Judge Harding Clark should be asked to advise on an appropriate scheme of redress arising from the findings of her report. We are pleased she has agreed to do so. She will also advise on the cost of such a scheme and a mechanism for ensuring the maximum recoupment of such costs from wrongdoers and indemnifiers. Judge Harding Clark has the highest confidence of everyone involved and is the best person to advise the Government on this matter. She will commence her work immediately and will bring her proposals to me as soon as possible.

I will not attempt to summarise the report for the House. I am sure Deputies have read it in its entirety, as it fully deserves. I urge everyone concerned with our health services and the wider public to do so also. As Judge Harding Clark states, many aspects of the report that are "truly shocking" while others still seem inexplicable and others are simply outrageous and leave us angry.

Beyond the failings of medical practice and reporting, what was particularly outrageous was the interference with and removal of personal medical files of the women affected. It is chilling to read that the inquiry found that in 44 cases, obstetric hysterectomy records for the period 1974 to 1998 are missing and were intentionally and unlawfully removed from the hospital. In 40 of the 44 cases the birth registers are also missing. This is not explained by medical practice and culture in times past but relates to cases up to eight years ago. It was an appalling theft of the key to the truth from the same women who had been robbed of their fertility. This is unfinished business and I earnestly hope the Garda can bring the perpetrators to justice. I believe Judge Harding Clark's report will be helpful in that matter.

The report highlighted the urgent need for change and reform in our hospitals and clinical governance. Some of the lessons it captures are that any isolated institution which fails to have in place a process of outcome review by peers and benchmark comparators can produce a similar outcome to that which occurred in Our Lady of Lourdes Hospital; support systems must be in place to conduct regular and obligatory audits; there must be mandatory continuing professional development and skills assessment at all levels of health care; staff need to attend updating of skills and methods programmes and should be able to recognise that procedures change in accordance with evidence-based research; and outmoded and unnecessary practices should be recognised as such and changed as soon as information is available.

The recommendations in the report underline the importance of the policies and actions already being taken in three key areas: the new medical practitioners Bill which I hope, subject to Government approval, to bring to the House later this year; the new contract for hospital consultants which is urgently needed for the recruitment of hundreds more consultants; and changes in management systems and quality assurance within hospitals.

Patient safety in hospitals should be as rigorous as passenger safety in airlines. This must mean a sea-change in culture, as it did in the airline industry. It will mean a culture of openness and preparedness to acknowledge errors and an ability to analyse clinical practice in an environment which does not resort to blame and recrimination. Blame-free reporting is vital, as is analysis of the full facts of events. Most important of all is implementing the lessons learned to achieve constant improvement in patient safety and outcomes. This involves much more than so-called whistleblowing. It is a systematic, continuous and open approach to error reporting and correction involving everyone in the health care setting. It entails a rigorous process of audit, peer review and external evaluation and is the only way to achieve maximum patient safety.

The culture will change, not simply in the degree of deference to be shown to consultants or the personal attitude of individual consultants. Consultants are no different from anyone else. They respond to the powers and responsibilities, incentives and penalties and the individuality and teamwork of the system in which they work. This is the reason the only adequate response to this report is systemic reform and change.

The cornerstone of legislation on medical practice is the Medical Practitioners Act 1978 which provides for the Medical Council to regulate the medical profession. The Act has been amended at various times in the past 28 years and a complete overhaul and replacement for it is being prepared. Work on the new medical practitioners Bill is well advanced and I intend to make available the heads of Bill to interested stakeholders, including Members, as soon as possible. All stakeholders will have the opportunity to comment to assist in the drafting of the Bill proper, which the Government intends to publish later in the year.

The recommendations of Judge Harding Clark's report will be addressed in the Bill in a variety of ways. The Bill will underline the Medical Council's role as the body in this State which acts to protect the public by way of regulation of the medical profession. It will introduce more streamlined and transparent procedures for the processing of complaints and modernise registration processes to allow for flexibility where required. It will integrate registration, education and training, ongoing competence and fitness to practise processes and clearly define the responsibilities of the council in the education and training of medical practitioners. It will also provide, for the first time, a legal framework for the Medical Council's implementation and administration of a system of competence assurance. It is intended that the new legislation will make continuing professional development and education compulsory for medical practitioners.

The purpose of the Medical Council is not only to provide a registration service for medical practitioners. It must also be seen as the competent authority for dealing with serious allegations of professional misconduct. Patients require assurances that their interests are paramount and override any sectional interest. For this reason, I believe that any self-regulating professional organisation should have a majority of non-members on its governing board and I will propose this approach for the Medical Council.

The new medical practitioners legislation will be complemented by the Health and Social Care Professionals Act and other forthcoming legislation governing nurses, midwives, pharmacists and dentists. All this legislation will have a common purpose of ensuring robust governance, clarity of procedures and formal systems of accountability which are aimed at the protection of the patient while at the same time recognising the need for due process when processing allegations against health care professionals.

The Lourdes hospital inquiry report has affirmed the approach being pursued by the Government and Health Service Executive in the negotiation of a new contract for hospital consultants. The necessity for improvements in team working by consultants is clear. The report reinforces our proposals on the contract regarding the need for clear clinical leadership, which will ensure that individual clinical practice is in line with acceptable standards of practice. In addition, the need for a much more rigorous audit of consultant activity is beyond question.

The report also highlights the necessity to have clear responsibility for the training of non-consultant hospital doctors. The Fottrell and Buttimer reports and the new contracts proposed for non-consultant hospital doctors show a clear pathway for the education, training and support of doctors in the Irish health care system throughout their careers.

Clinical governance is about more than clinicians. Effective systems of clinical governance are vital to ensure quality care for patients. These systems need constant review. Previously, we have had very weak clinical governance and oversight in our health system. We need to identify and tackle the weaknesses that exist in every part of the health system, be they regulatory, governance, organisational, managerial or clinical. It is my intention to come to Government presently with proposals to establish a mechanism to ensure that, in particular, clinical governance arrangements are strengthened throughout the health system and not only in the regulation of medical practitioners. In a further step towards quality assurance for patients, the Government yesterday approved the publication for consultation of the heads of the Bill providing for the establishment of the health information and quality authority, HIQA, on a statutory basis. HIQA will set standards and will have powers to investigate most services provided by or on behalf of the HSE.

This report is a call to action. It is a call on everyone involved in health care to embrace change and to take responsibility for a new system that makes patient safety the first and irreducible standard of care. I believe the Medical Council is ready for change, as are many consultants, hospital medical boards, managers and nurses and midwives in the frontline of care. The Government will not be found wanting in its response to Judge Clark's recommendations on a redress scheme, in legislation on clinical standards and medical practice and in the new hospital consultants' contract. We will also bring forward systematic clinical governance to ensure patient safety and quality care.

I believe that in the Oireachtas, as in the country, there is a palpable determination to do all we can to prevent this ever happening again. In this House, we are aware of our differences but we are also aware of our responsibilities, including the responsibility to legislate effectively on grave matters that affect the safety and well-being of the entire population. We will discharge that responsibility; we owe nothing less to the women referred to in this report.

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