Mary Harney (Dublin Mid West, Progressive Democrats)

In 2005, it was 51 cases. In 2002 it was somewhere in the 60s. As screening began, it declined because the screening programme is attached to clinical care, unlike other countries, so that where breast cancer is picked up the woman is treated at the centre. In this case it would have been St. Vincent's Hospital in Dublin.

I reiterate that we cannot undo the past but must learn from it. We never investigated these matters in the past. The Dr. Neary episode continued for 25 years, even though there were people working with him. Thankfully, in the end midwives, specifically someone who came from outside this jurisdiction, blew the whistle. People knew for a 25-year period that something wrong was happening there. If we had audit and data we would have seen that what was happening in the maternity unit at Our Lady of Lourdes Hospital was completely different from what was happening elsewhere by a margin of 20 times. When issues came to light, matters were not investigated. We are now in a new era with many investigations, difficult and unpalatable as they are.

To revert to Deputy Flanagan's question, there were 46 cases in 2002.

These investigations are challenging for those who work in the health system and they are challenging for patients. It is also challenging in respect of confidence in the health system but if we have no standards we can improve nothing. If we do not have determination to implement the standards, we do not improve matters. If it was not for the director of nursing, who was concerned about over-diagnosis, as Mr. Fitzgerald stated, we would not have picked up on these nine errors. If the director of nursing did not get in touch with the HSE last August and express concern at over-diagnosis or false positives, we still would not know what is happening in Portlaoise. We owe her a great deal of gratitude. The HSE put the doctor on administrative leave, which is normal practice, and carried out a review and investigation. We know the outcome of the clinical review.

The second matter is the management of the issue. I was concerned, particularly after information was given at the meeting of the Oireachtas Joint Committee on Health and Children on the ultrasound review. I asked the board of the HSE, which is appointed by and accountable to me, to examine what happened and see what lessons have been learned. Clearly, there were serious failings of management, communication and governance in respect of how Portlaoise was handled. The most important matter with regard to these findings is that we discovered what happened. Accountability is about getting the facts, identifying what must be done to address failings and implementing the steps taken to address the failings. The serious issues identified must be put right and it is my responsibility to ensure the board of the HSE puts them right. I have asked the Chairman of the HSE to ensure that happens in regard to incidents of this kind; we know there will be more incidents of this kind because there will always be clinical error. We can only minimise it when we have groups of doctors working together in teams in large centres. When incidents and errors occur we must have protocols that are patient-centred and we must ensure patients come first. I want to give a guarantee that when errors of this kind arise, patients will be contacted directly and not hear about it through the media or the political system. I have asked the HSE to consult patient groups, many of which wish to be involved, when drawing up the protocol. I want one person in charge to ensure the protocol is implemented. We see from the Fitzgerald report that a plethora of people involved in the one incident leads to confusion, mismanagement and serious governance and communication issues. I want to ensure the board of the HSE through its risk assessment committee oversees this.

I have many more comments to make, but if there is any lesson we must all learn, it is that we must rapidly ensure that we implement the new cancer plan around the eight specialist centres. They are not centres of excellence — as every health setting should be a centre of excellence — they are specialist centres. Above all else, we must learn from what occurs in respect of children's cancer. As it is centrally organised at Our Lady's Children's Hospital, Crumlin — although many of the treatments are delivered in 16 places — we exceed the best performers in Europe and the United States. That proves that appropriately organised care in cancer delivers a good outcome for patients. This debate concerns patients, putting them first and investing necessary resources in the eight centres to have them fully operational as quickly as possible.

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