James Reilly (Dublin North, Fine Gael)

The wording of the motion I have moved deserves to be emphasised, particularly the section in which we call on the Government to establish a patient safety authority to ensure "investigations take place when and where" necessary. As things stand, such an authority is not being established, unfortunately.

We are having this debate on foot of another serious scandal - the misdiagnosis of miscarriage in pregnant women, which is mentioned in the motion. This problem has emanated from Our Lady of Lourdes Hospital in Drogheda, which has been beset by difficulties and scandals over the years. In recent times, the serious pressure on the hospital has become even more horrendous as a result of the Government's deliberate policy of stripping essential services from hospitals in the surrounding counties and moving them to Drogheda. This approach is making it more difficult for the staff of the hospital, who have an increased workload, to carry out their duties with any degree of safety.

I wish to give an example of the problems encountered during foetal assessments. A lady told me that the person who performed the ultrasound on her was bleeped on three separate occasions during the course of the short examination. Anybody who knows anything about learning knows that concentration is important. We all know that anxiety interferes with concentration. If a bleep goes off in one's pocket, it is not just distracting - it creates anxiety too. One will be distracted while one performs this important examination if one is aware that somebody is in great trouble and needs one's services.

It is important to remind the House what happened to Melissa Redmond. Eight weeks into her pregnancy, on 22 July 2009, Melissa Redmond went for a scan in the early pregnancy unit of Our Lady of Lourdes Hospital in Drogheda. It should have been an occasion of joy and hope, but instead it was a devastating experience. She was advised that her unborn baby was dead, eight weeks into her pregnancy. A dilation and curettage procedure was arranged for two days later, on 24 July 2009, and she was given an abortive drug to take on the morning of the operation. The drug in question is designed to open the neck of the womb to make the procedure easier. We must bear in mind that a dilation and curettage procedure involves the evacuation of the contents of the womb. If there is a live foetus in the womb, its life will be terminated as part of the procedure. A report on TV3 last night referred to an extraordinary case in which a probable twin survived a dilation and curettage procedure. That is highly unusual.

Fortunately, Melissa Redmond had sufficient strength of character to seek a second opinion. In that context, I will speak later about the gross unfairness in our system. As she had already had two children and suffered four miscarriages, she was not prepared to allow matters to rest there. She went to her general practitioner in Donabate, who gave her another scan, which found that the baby was alive. The baby was born healthy, thankfully, and is now alive and well. I am sure the Redmonds would have nothing but good to say about the staff who looked after Melissa for the rest of her pregnancy, subsequent to events at Our Lady of Lourdes Hospital.

After the story broke, the HSE said the wrong diagnosis of miscarriage, such as that in this case at Our Lady of Lourdes Hospital in Drogheda, was "extremely rare". This was contradicted by women who came forward with similar experiences over the following days. To date, approximately a dozen women have told stories of wrongly being informed by maternity hospitals that their babies had been miscarried, only to give birth to healthy infants at a later stage. The HSE has received almost 300 telephone calls from concerned women and their families about the treatment they received in maternity hospitals throughout the country.

It is important to remind the House that when different people make the same mistake in different locations, there is a problem with the system. If the same person makes the same mistake, clearly there is a problem with the person. Nobody should doubt not only that we have a problem with our system, but also that we have a problem with who runs the system. This problem was not addressed immediately to ascertain its prevalence. We had to depend on brave and strong people like Melissa and Michael Redmond, who were prepared to forego their privacy and to let the country know, through the media, what happened to them. This resulted in other women coming forward with their stories.

Although we realise we have a problem that requires investigation, the Minister for Health and Children will not order an independent investigation. The Minister, Deputy Harney, wants the HSE to investigate the HSE. She has been a stalwart proponent of not allowing the medical profession to investigate the medical profession, or the dental profession to investigate the dental profession. I agree with her that the days when any profession or group - the Garda or other body - was allowed to investigate itself are over. We need third party verification. We need to be assured that those conducting investigations do not have any conflict of interest.

There have been other cases of misdiagnosis. Martha O'Neill Brennan from Galway told her story.

In both these cases, the women trusted their instincts, stood up to the system and insisted on a second scan. Both are right and both have since given birth to healthy babies. Michael and Melissa Redmond have since said they were disgusted by the HSE's reaction to the misdiagnosis.

An internal review showed that the equipment was faulty and the facilities inadequate. The inquiry found that the image resolution on the ultrasound machine in the early pregnancy assessment unit was not adequate to accurately assess early pregnancies and their complications and that the machine displayed evidence of fatigue. The internal review recommended that the equipment be updated to ensure it was fit for purpose. Despite this, the scanner continued to be used until January 2010, six months after the incident. The review also suggested that a dedicated ultrasonographer be recruited to the unit. One year on, that position has still not been filled. What is the recommendation from this, so called, independent HSE report? It is that we get a sonographer for four hours a day. This maternity unit delivered more than 4,000 babies last year. By any international standard, having spoken to professionals in this area, there should be at least two, if not four, whole-time equivalent sonographers available and not the proposed half-time equivalent, who still is not present.

This puts me in mind of the self serving system the HSE has become. It looks to itself and its own convenience before it looks to patient care.

I congratulate the Redmond family of Donabate and others who have come forward with their experiences. It is not fair to expect devastated couples, who have just been told they have lost their unborn child, to have the composure, confidence and courage to demand a second opinion. It should happen as a right. A patient centred service would listen and ask. Our service thinks only of the inconvenience to itself, as encapsulated by another woman who told of asking, when she was on her way to have a D and C, for a second scan. She was told that was not possible. When she continued to insist she was further informed that not alone was it not possible but that is she did not stop insisting she would miss her slot in the queue and would not have her D and C for another week. Is this a demonstration of compassion, of caring or of a patient centred service. The ethos of the HSE has become something horrible and not something of which anyone in this Chamber can be proud. I can give example after example of that.

Meanwhile, the HSE has announced it is developing national guidelines for clinical practice in obstetrics care. It has announced the establishment of a miscarriage diagnosis review to examine the cases known or identified in the past five years. The review has subsequently expanded to cases beyond five years. While we recognise and welcome the decision of the Institute of Obstetricians and Gynaecologists at the Royal College of Physicians of Ireland to develop its own guidelines in conjunction with the HSE so that it will standardise practices at a high level and welcome the announcement of the HSE review, this is not enough.

The Minister for Health and Children and the HSE must call on HIQA to conduct an urgent audit of ante-natal and maternity services, including the standard and safety of equipment, staff workloads and the workload on equipment, care protocols and training of personnel. This is critical. I am given to understand there are not many more than 120 ultrasound machines involved in foetal assessment. How long could it take to assess those? A year after this matter arose privately between the hospital and Melissa Redmond - the HSE was aware of it - this has not happened. The lethargic, lazy approach of the HSE to these issues, which are so important to patient care, is not acceptable. Matters are put on the long finger and patients are left at risk, instead of urgent action being taken as would happen in a proper patient centred service rather than the self service system we have.

We call on the Government to establish a dedicated independent patient safety authority that would incorporate HIQA, reassure patients that they have a safe place to go with their complaint, act as an advocate for them and ensure that investigations take place when and where necessary.

Our Lady of Lourdes Hospital has had an unfortunate history. It has been mired in a series of scandals and controversies, many of which centred on the standard of care given to pregnant women. Given the number of scandals, one would expect the hospital to be extra vigilant when dealing with patient safety and care. Instead of this, patients attending Drogheda and other hospitals around the country often feel let down and ignored by the system.

Do I need to remind Members of what has happened in this hospital and how people in the north east of the country have been let down? I know I do not have to remind my colleague, Deputy Fergus O'Dowd. The disgraced obstetrician Dr. Michael Neary was struck off the medical register in 2003 after an investigation found he had needlessly removed the wombs and ovaries of dozens of expectant mothers. Garda Sergeant Tania Corcoran-McCabe died, along with one of her twins. An inquest returned a verdict of death my medical misadventure in relation to the young mother. I sympathise with her family. Symphysiotomy procedures were carried out there long after the practice has ceased elsewhere. Mother Kathleen Naughton, who is still living with the consequences of the symphysiotomy she underwent there 35 years ago, said doctors at the time considered themselves to be "gods". There was also the terrible case of abuse by Michael Shine. We now know the great work done by Dignity for Patients.

Would these groups need to exist if a patient safety authority had been in place? Would medical people have been allowed to continue with their practices had a patient safety authority existed, which would have been an advocate for complainants and would have been independent and not employed by the hospital? Complaints officers in the hospitals are employees of the hospital. Where does their loyalty lie?

Thousands of X-rays had to be reviewed after a locum radiologist mistakenly gave the all-clear to nine lung cancer patients, eight of whom subsequently died. The radiologist worked at Our Lady of Lourdes in Drogheda and Our Lady's Hospital in Navan between August 2006 and August 2007. How did the HSE react? It knew about it. My colleague, Deputy Fergus O'Dowd, through a freedom of information request, established that the HSE knew about this real danger to patients in September 2007 and took no action until May 2008. This lazy, lethargic approach screamed at patients, "We'll deal with you when we are ready. In the meantime, you take your chances."

I will now refer to Portlaoise and the disgraceful situation where a consultant surgeon, having reviewed the files in fives and sixes, gave them to an official who put them in a room and left them there until a "cohort" was reached. What was the cohort to be? Was it 100 or 200? It did not matter that these women might have had breast cancer - some did. That was not the issue. The system would deal with these people when it was good and ready. That is not the system in which I grew up or was trained. It is not the system that pertained prior to the installation of the HSE.

In Tallaght, a local general practitioner highlighted the X-ray issue in April. The HIQA became involved in June. It interviewed people in August and in December the Minister was informed. She was not told the extent of the problem and she did not ask because she did not want to know. Months went by before the issue was properly addressed. Once a problem was acknowledged and recognised, all the X-rays - which were digital - could have been e-mailed to radiologists throughout Ireland and the United Kingdom and the matter could have been resolved within weeks. Instead, it was left on the long finger because, once again, the system served itself, and the patient was left to wait. I wish to mention, in particular, the tragedy in Ennis Hospital, where Ann Moriarty twice attended and was given the all-clear. She also went to St. James's Hospital and was again given the all-clear.

The Minister stated last week that HIQA could be the patients' safety authority. HIQA has told me it cannot be a patient safety advocacy. However, it could be subsumed into a patient safety authority. I would like to talk about all the other matters on which it could advise and over which it could preside. Will we find ourselves here again talking about the plight of our young people with cystic fibrosis who still have no isolation unit? They were promised one would be built this year but it has not yet even been tendered for properly.

All the issues I spoke of would have come to light earlier if a patient safety authority were in place. Consider the situation people must go through in seeking redress for their hurt young, having to mortgage their homes to get justice for their children. I urge the Minister not to miss this opportunity to instruct HIQA to undertake an investigation and give people back faith in their health service. They do not trust the HSE and a HSE investigation will not do it for them. I would like to see an audit of our maternity and ante-natal hospital services performed by HIQA but, most of all, I plead with the Minister to take this opportunity to set up a patient safety authority and restore some faith in our health service.

See this speech in context