Colm Keaveney (Galway East, Fianna Fail) | Oireachtas source

It is a fact that there has been a general failure to investigate the contributory factors to the deaths involved. The report clearly indicates that the Department's failure to adhere to the legislation and the regulation has resulted in a collapse in a standardised approach. That only one in eight of the investigations undertaken was consistent with the approach set out by the systems analysis methodology, to which the Minister referred, is unacceptable. If we are to learn anything from the crisis within the country with respect to death by suicide we need to establish where the systems are breaking down within the HSE and why validation of compliance was not possible in cases due to, for example, the lack of supporting documents, maintaining files and adhering to standing operational procedures.

We are failing the most vulnerable people by failing to ensure we follow regulation procedure in this respect.

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