Eamon Gilmore (Dún Laoghaire, Labour) | Oireachtas source

There should be no issue of exoneration at any level regarding this issue. This is not a time for anybody to be exonerating themselves. I have been through the report which is very good and detailed, albeit using some of the guarded language that these reports use. I believe it gets to the nub of where the problems are. At every level actions need to be taken to address what is in this report and to implement its recommendations.

As the Deputy has said, there was a previous case in 2007 and there was to be follow-up on that. The report states:

The HSE reported that these recommendations were implemented at a local HSE level with regional HSE oversight. On enquiry, the Authority noted with concern that only five of the 19 maternity hospitals/units were able to provide a detailed status update on the implementation of recommendations from the Tania McCabe report.

Referring to what happened in Galway the HIQA report states:

The Hospital reported that 167 maternity and non-maternity patients in total required ICU care as a result of sepsis in 2011 and 139 patients in 2012... the Authority [HIQA] found that at the time of the investigation, the Hospital did not have a hospital-wide guideline in place for the management of sepsis in adult patients.

We need to ask why that was. That issue needs to be addressed. The HIQA report also states:

The Hospital had a guideline in place for the management of 'Suspected sepsis and sepsis in obstetric care'. However, the clinical governance arrangements were not robust enough to ensure adherence to this guideline.

What does that mean in plain language? Does it mean somebody was not implementing or enforcing those guidelines or does it mean there was an attempt to enforce them and they were not complied with? That needs to be addressed. We need to take this report in its totality. It does not spare any level of the health service, from the ward to the Minister's office. I believe it needs to be taken seriously. It needs to be answered and addressed, and its recommendations need to be fully implemented.

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