James Reilly (Dublin North, Fine Gael) | Oireachtas source

I move amendment No. 3:

To delete all words after "Dáil Éireann" and substitute the following:

"extends its deepest sympathy to the family of Ms. Savita Halappanavar and recognises the very strong feeling of the Irish people in the wake of her death;

awaits the outcome of the investigation into Ms. Savita Halappanavar’s death to be chaired by Professor Sir Sabaratnam Arulkumaran;

welcomes the submission to the Minister for Health of the report of the expert group to address the judgment of the European Court of Human Rights in the A, B and C v. Ireland case and recognises that this group was established on foot of a commitment given in the programme for Government;

notes that the terms of reference of the expert group were as follows:

— to examine the A, B and C v. Ireland judgment of the European Court of Human Rights;

— to elucidate its implications for the provision of health care services to pregnant women in Ireland; and

— to recommend a series of options on how to implement the judgment taking into account the constitutional, legal, medical, and ethical considerations involved in the formulation of public policy in this area and the overriding need for speedy action;

acknowledges the complexity and sensitivity of the issues involved and supports the Minister for Health’s decision to bring the report to Government on Tuesday, 27 November and his recommendation that it be then published immediately; and agrees that the report of the expert group should be discussed in the Houses of the Oireachtas over the coming weeks in advance of a Government decision on the matter and that the Whips should meet to make the arrangements for such discussions at the earliest opportunity."

First, I would like to extend my deepest sympathy once again to the family of Ms Savita Halappanavar on their loss. We all recognise the very strong feelings that her death has caused in Ireland and abroad. I have been struck over the past week by the outpouring of grief and sympathy from people all over this country on this tragic death and yet I know this can only be a fraction of what the family must feel.

As I mentioned many times before, my aim and the role of my Department is to improve the health and well-being of people in Ireland in a manner that promotes better health for everyone, fair access, responsive and appropriate care delivery and high performance. In particular, our focus is to ensure the provision of a safe, quality assured patient-centred and efficient health service. Nationally, we are focused on ensuring patient safety, quality and excellence in our health care system. It is important, therefore, that we have systems in place to minimise risk of occurrence and to detect and respond appropriately to them when they occur.

The internal HSE procedures for dealing with serious adverse events and incidents have improved and strengthened in recent years. Important developments in this area included the establishment of the directorate of quality and patient safety in the HSE, the enhancement of clinical governance and the ongoing development of the clinical care programmes in the HSE. Important contributions to patient safety have been made through HIQA reports and the safer better health care standards published in June this year will also enhance patient safety.

As reported widely in the media, the Department of Health was advised by the HSE of a maternal death in UCHG on 28 October 2012. The incident was escalated directly from the hospital for the attention of the HSE's national incident management team on 1 November. This was done in accordance with its risk and incident escalation procedure which outlines the steps that must be taken by each manager to escalate risks and incidents, as appropriate, that occur within their own service. This procedure is to be used in circumstances where a national or integrated response is required.

The HSE has established an investigation into the death of Ms Savita Halappanavar. The purpose of the investigation is to establish the factual circumstances leading up to the incident; identify any key causal factor that may have occurred; identify any of the contributory factors that may have caused the key causal factors; and recommend actions that will address the contributory factors in order that the risk of future harm arising from these factors is eliminated or, if this is impossible, reduced as far as is reasonably practicable. The period covered by the investigation will be from the patient's admission to University Hospital Galway on 21 October to the patient's death on 28 October. I have been assured that the investigation will be conducted in the shortest timeframe necessary to achieve its purpose. That purpose is, first, to get at the truth and not to leave her family in doubt any longer than is absolutely necessary about what happened and, second, to reassure the many women in this country who use the health service that any practice that might not be safe has been addressed. I have been informed that, through the chairperson, the investigation team will be afforded the assistance of all relevant staff and other relevant personnel and will have access to all relevant files and records, subject to necessary consent and data protection requirements.

The HSE's national incident management team, NIMT, will oversee and support the investigation into the circumstances of Ms Savita Halappanavar's tragic death. University Hospital Galway has committed to co-operating fully with the team to ensure the investigation can be completed as quickly as possible. Sir Sabaratnam Arulkumaran, an independent expert in obstetrics and gynaecology, will chair the investigation team into Ms Halappanavar's death. He is professor and head of obstetrics and gynaecology and deputy head of clinical sciences at St. George's University of London. He is also president of the International Federation of Gynaecology and Obstetrics.

The investigation team will comprise a number of experts in the relevant disciplines, including anaesthesia, midwifery, obstetrics and gynaecology, to review the full range of clinical care provided for Ms Savita Halappanavar. The team also includes an independent patient representative and an expert in infectious diseases. I am aware that Mr. Halappanavar has raised concerns about the membership of the investigative panel in respect of three consultants employed in University Hospital Galway and about the investigation in general. As regards the inclusion of three hospital consultants from Galway, having reflected on the concerns raised by the family, the HSE has agreed that these three consultants will step down. It is in the process of identifying suitable replacements in the relevant clinical disciplines. As per HSE policy, the investigation team will work closely with the family at all times and keep them fully informed of the terms of reference of the investigation. The chairperson is now seeking to meet Mr. Halappanavar to address his concerns and update him on the new membership of the investigation team. It is hoped he will obtain Mr. Halappanavar's co-operation with the inquiry.

With regard to the claim that the HSE would not have investigated the matter had there not been public pressure to do so, all such incidents are investigated routinely. The investigation process in this case had commenced prior to the reporting in the media. As is usual with such cases, the HSE has an internal investigation process which it carries out. There are, sadly, incidents of deaths that occur in the health service that require investigation. This occurs in health services in other jurisdictions in any given year. One of the principal objectives of investigations is to establish the factors relating to a particular case. It is also essential that findings that would help to prevent death or serious injury to other service users are identified. In the vast majority of health care incidents it can be shown that environmental system factors are often a contributory factor. To ensure factors which may contribute to an error prone environment are identified, it is important that staff feel safe and in a position to respond positively to inquiries without fear of jeopardising their rights should future investigations take place.

This is not the first serious incident the HSE has investigated. It has a record of carrying out investigations that are thorough and identify all the safety problems and solutions that need to be identified. When the miscarriage misdiagnosis cases first emerged, there were widespread calls for a full independent public inquiry. The HSE carried out an investigation with an external independent chairperson, the findings of which were uniformly accepted on publication by both the public and the service users. The individual who had raised concerns initially was satisfied with all aspects of the investigation and maintained that if all of the recommendations were implemented, services would be safer for women. The HSE has a record of carrying out investigations that find everything that external independent inquiries would. In the case of the transfer of a young patient for a liver transplant the findings of the HSE investigation were published on the same day as the external independent inquiry report by the Health Information and Quality Authority, HIQA. The HIQA investigation did not find anything that the HSE investigation had not. The final report of the investigation team will be provided for the HSE's chairman and me as Minister. In addition, a coroner's inquest will take place into this sad case, as would be expected.

There is a long history of obstetric audit in this country. Maternal deaths are always intensively investigated and in recent years arrangements have been put in place for Irish maternal deaths to be reported to the UK confidential inquiry system to ensure maximisation of learning and inform future prevention. This country is one of the safest in the world to have a child.

It would be inappropriate to comment further on the circumstances and possible causes of Ms Savita Halappanavar's death until the HSE investigation has run its course. However, it is important to point out that women in Ireland are entitled to legal clarity about what happens in a case where a woman's life is at risk. This issue has been with us for a very long time. As Deputies are aware, the current legal position on abortion in Ireland is set out in Article 40.3.3^oof the Constitution as interpreted by the Supreme Court in the 1992 case. It provides that it is lawful to terminate a pregnancy if it is established as a matter of probability that there is a real and substantial risk to the life, as distinct from the health, of the mother, which can only be avoided by a termination of the pregnancy.

In addition, the current Medical Council's Guide to Professional Conduct and Ethics for Registered Medical Practitioners 2009 sets out the position on abortion as follows:

21.1. Abortion is illegal in Ireland except where there is a real and substantial risk to the life (as distinct from the health) of the mother. Under current legal precedent, this exception includes where there is a clear and substantial risk to the life of the mother arising from a threat of suicide. You should undertake a full assessment of any such risk in light of the clinical research on this issue.

21.4. In current obstetrical practice, rare complications can arise where therapeutic intervention (including termination of a pregnancy) is required at a stage when, due to extreme immaturity of the baby, there may be little or no hope of the baby surviving. In these exceptional circumstances, it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby.

These provisions came under scrutiny in December 2009 when the European Court of Human Rights heard a case brought by three women in respect of the alleged breach of their rights under the European Convention for the Protection of Human Rights and Fundamental Freedoms in regard to abortion in Ireland - the A, B and Cv. Ireland case. All of the applicants were women who had unintentionally become pregnant and travelled to the United Kingdom for an abortion. The judgment of the court in the A, B and C v,Ireland case confirmed that Article 40.3.3° of the Constitution was not inconsistent with the convention. It found that there had been no violation of their rights under the convention in respect of the first and second applicants, Ms A and Ms B, and dismissed their applications; there had been a violation of the applicant's right to private and family life contrary to Article 8 of the convention in the case of the third applicant, Ms C. It held that there was no accessible and effective procedure to enable her to establish whether she qualified for a lawful termination of pregnancy in accordance with Irish law. It ruled that "no criteria or procedures have been ... laid down in Irish law ... by which that risk is to be measured or determined, leading to uncertainty..." and held that further legal clarity was required. The third applicant, Ms C, had been treated for cancer for three years. At the time she had unintentionally become pregnant she was in remission and, being unaware of this fact, presented for a series of follow-up tests related to her illness which were contraindicated during early pregnancy.

She was unable to obtain clear medical advice about the effect of the pregnancy on her health or her life or as to the effect of the medical treatment on the foetus, and feared the possibility the pregnancy might lead to a recurrence of the cancer. She decided to have an abortion and travelled to the UK for the procedure.

Ireland has signed and ratified the European Convention on Human Rights, Article 46 of which states that signatories agree to abide by any judgment of the court in any case to which they are parties. Ireland is, therefore, under a legal obligation to implement the judgment of the European Court of Human Rights in A, B and C v. Ireland. Supervision of Ireland's execution of the judgment falls to the Committee of Ministers of the Council of Europe. On foot of the judgment, and to fulfil a commitment included in the programme for Government, the Government established an expert group, drawing on appropriate medical and legal expertise, with a view to making recommendations on how this matter should be properly addressed. The expert group was established in January 2012 and its terms of reference were to examine the A, B and C v. Ireland judgment of the European Court of Human Rights, to elucidate its implications for the provision of health care services to pregnant women in Ireland, and to recommend a series of options on how to implement the judgment, taking into account the constitutional, legal, medical and ethical considerations involved in the formulation of public policy in this area and the over-riding need for speedy action.

The expert group was made up of experts in the fields of obstetrics, psychiatry, general practice, law, professional regulation and public policy. It was chaired by a judge of the High Court, the Honourable Mr. Justice Sean Ryan. The expert group submitted its report to me on 13 November and I am currently examining the document. The Taoiseach and Tánaiste have also received a copy of the report and I intend to recommend its publication to Government on Tuesday, 27 November.

As I said last April in the House, I am sure Members share my view that it is incumbent upon us as public representatives to take action to deal with a long overdue responsibility. We need to make sure we take the necessary action to protect the lives of women. However, these are extremely complex matters and deserve thoughtful consideration from a clinical and legal perspective. I will be studying the contents of the expert group report and will be discussing it with my colleagues in government and legal advisers. In the meantime, I look forward to a thoughtful and considered discussion on the report in the Houses of the Oireachtas in the coming weeks. The discussion will be invaluable and will assist the Government in formulating proposals to ensure the safety of pregnant women in Ireland is maintained and strengthened and that we can fulfil our duty of care towards them. It is my intention this can be done as expeditiously as possible and I look forward to hearing many views from all sides of the House on a difficult issue that divided not just the country but families over the past 20 years.

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