Billy Kelleher (Cork North Central, Fianna Fail) | Oireachtas source

I welcome the contributions from all sides of the House. I read the Minister's speech again this morning, in which he mentioned that we should not play politics with this issue. I certainly was very reluctant to go down the political route without first having listened to the testimonies of the families and read the indepth reports of the CMO and HIQA but I would be failing in my duties if I did not bring this matter to the floor of the Dáil to ensure we had a proper discourse and debate on the issue of our maternity services in Portlaoise and, to say the very least, the appalling failure of systems and, perhaps, of individuals as well.

Many of the families, including Amy Delahunt, Ollie Kelly and Mark and Róisín Molloy, told us of their experiences. Last week, I asked Róisín Molloy at the health committee about treatment by the HSE and if it had changed. Her response was: "We were treated with complete disdain. They hated us." I wrote down those words as she expressed them, which were a damning indictment of individuals within the system. I am always reluctant to point the finger at individuals but we cannot always hide behind systems failures. Staff, particularly those in senior management posts, must share in responsibility. This is not about witch-hunting or scapegoating. That is certainly not the motivation of the families. I have met with the Molloys, Ollie Kelly and Amy Delahunt and I have spoken to others as well. They are not interested in witch-hunting. What they want is an element of accountability for the purpose of ensuring that this does not happen again. Unfortunately, it has happened again in the context of HSE local management and administrators and regional management and administrators and so on informing families that this was a once-off and that it had not happened before and would not happen again. The unfortunate reality is that it was happening all too often in the context of Portlaoise hospital.

If we are to learn anything from this very tragic saga it is that we need to have a system in place that can access information, collate it and ensure that people who failed in their duties or ability to manage are identified early. Within any system, a weak individual will weaken the entire system. This, unfortunately, in my view, is the case in the context of the HIQA report, throughout which is highlighted the failure in governance across Portlaoise hospital, including at regional and national management level. The HIQA report states on page 135:

During this investigation, the Authority found that Portlaoise Hospital and the Health Service Executive (HSE) at local, regional and national level were aware for many years of numerous patient safety risks in the hospital but failed to act decisively to reduce these risks.

It continues to elaborate on that failure. Without sanction and the ability of individuals to hide behind systems failure we will consistently have systems failure. I am not interested in any junior clerical officer being identified as at fault. What we need is some degree of accountability at all levels. When people are remunerated in management positions with that responsibility comes an onus to carry out that responsibility and if it is not carried out sanction must follow. This must be done, and not only in the context of the health services but the higher echelons of our public service and, in particular, our Civil Service. Where people are remunerated according to their responsibilities and they shirk or fail in their duties sanction must be brought to bear.

Until such time as we see that change in attitude, with people at senior level being held accountable, we will not change the system because, regardless of what we think, the motivation to change will not be present and the herd mentality will prevail. We talk about groupthink, but we know where it got us. We had groupthink in this Chamber, the Central Bank and many other places and know where we ended up. Groupthink or group protection in these areas could cause huge difficulties.

When we read the report on Portlaoise hospital and listen to the contributions from some sides of the House, it is clear that those contributing have not read the full report if they say this is not about resources. It is about resources. On page 135 of the report a failure to act decisively to reduce risks in the context of management is reported. On page 138 it speaks about general hospital services and states diagnostic imaging services were significantly underresourced and that the hospital did not have a strong clinical governance structure. Another point made is that the intensive care unit infrastructure was unfit for purpose. This, again, is a resource issue. Also, the report states general medical services in the hospital were not resourced or structured to effectively implement the recommendations of the HSE's acute medicine programme. Many pages of the document refer to the fact that the hospital was under-resourced.

At the heart of this issue also is the fact that the small hospitals framework, on foot of the Mallow and Ennis hospital reports, made recommendations that were applied in Portlaoise hospital. We cannot pretend or deny that inside this House, or somewhere else, a decision was made to exempt or remove Portlaoise hospital from the small hospitals framework, which effectively pointed out that there were deficiencies in these hospitals and that they would not have the capacity or the clinical governance structures in place or the throughput of patients to ensure safe practice in all areas. Clearly, there were difficulties. The report states the hospital was not structured to provide safe surgery, "as there are insufficient, acute and elective surgical presentations to ensure surgeons maintain the necessary competence and expertise". This is the reason Portlaoise hospital was mentioned in the original small hospitals framework because it did not have the required throughput of patients, yet a decision was made somewhere-----

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