Jan O'Sullivan (Limerick East, Labour)

I am referring to her appearance on television last week which I watched with a pen in my hand. I wrote down her comments on the lack of a culture of learning. From what I have heard today, I believe she is right. This motion pays lip-service to patients' interests, stating they will come first "in the future management of all such reviews and serious adverse incidents". However, patients need change that will ensure mistakes will not be made in the first place so that we do not need reviews of serious adverse incidents. None of the reports published thus far addresses the problems that caused the clinical errors. The Minister has repeatedly noted that the reasons for the misdiagnoses were clinical errors. However while I accept that a small percentage of clinical errors are unavoidable, the reason six times the normal percentage occurred in Portlaoise was because the system was wrong. The experts were not available because the appointments were not made. The issues raised by Peter Naughton in his letters to the former Minister, Deputy Martin, the current Minister and others in the HSE were not addressed. It was nobody's job——

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