Eamon Gilmore (Dún Laoghaire, Labour) | Oireachtas source

I join Deputy Kelleher in expressing again my sympathy and that of the Government to Praveen Halappanavar and his family on the death last year of his wife, Savita. The report published yesterday makes difficult reading for them and everybody with an interest in maternity services. I do not believe there is a woman in the country who does not put herself in that bed on St. Monica's ward and I do not believe there is a man in the country who does not see his wife, partner or daughter in that bed or ask himself very basic questions about it.

I have read the HIQA report and it does what the authority was asked to do, namely, to get to the bottom of what happened in Galway and why and to establish what lessons can be learned from it. As with all such reports, this report is written in careful language. Reading through it, however, a number of things become very clear. It correctly makes the point that everybody is entitled to be safe in our hospitals and to receive the best quality of care. It notes a general lack of provision of basic fundamental care, for example, failure to follow up on blood tests, failure to recognise that Savita Halappanavar was at risk of clinical deterioration and failure to act or escalate concerns to an appropriately qualified clinician when Savita Halappanavar was showing signs of clinical deterioration, and refers to ultimate clinical accountability resting with the consultation obstetrician who was leading the case. When one reads these points, one must ask fundamental questions about whether someone was not doing his or her job or not doing it properly.

The recommendations refer to governance failures, stating, for example, that the "clinical governance arrangements within the Hospital failed to recognise that vital Hospital policies were not in use nor were arrangements in place to ensure the provision of basic patient care on St Monica's Ward". When one reads this statement, one must ask fundamental questions about the management and supervision of the service. When one reads about the length of time clinicians were spending at committee meetings, one must ask basic questions about how the Health Service Executive is governed and run. When one reads the recommendations addressed to the HSE and Department and Health, one must ask basic questions about how maternity services are provided. When one reads, for example, that five of the nine maternity hospitals had not delivered on a previous report, one must ask fundamental questions about the delivery of a national maternity strategy in this case.

This is a very good report which contains recommendations that are addressed right across the board, from the hospital ward to the desk of the Minister for Health. These recommendations will be implemented. What we must do, and what Savita Halappanavar and the women of this country are owed, is to implement the recommendations with urgency and put in place systems, supervision and co-ordination to ensure we do not have another Savita Halappanavar case and the women of this country receive the maternity care and care in pregnancy to which they are entitled. This is what the Government and Minister for Health will address. While I am open to audits, independent examinations or other measures if they help to achieve or oversee this process and ensure it is completed, let us not go down the road of having another audit or report. We have a very good report; let us get on with doing what it asks us to do by implementing its recommendations.

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