Clare Daly (Dublin Fingal, Independent) | Oireachtas source

Mistakes happen no matter what systems are in place. Tragedies happen and they will continue to happen, but the issue facing us as a society is how we respond to those mistakes and tragedies, how we treat the victims of those mistakes and tragedies and whether we learn the lessons. I find the shock and horror expressed in some quarters a little hard to take. The saddest thing about this latest scandal is that it is just the latest one. It is not new to see the State Claims Agency taking people to war. It has been doing this for a long time. It is not new that the HSE drip-feeds information. Even tonight, the Minister has been put in the unenviable position of coming in here with new information. The Minister is continually being drip-fed and having to clarify information. We need to get to the heart of what is going on. This is the only way that we will serve Vicky Phelan and all of the other victims of our appalling health service.

The Minister correctly said that this issue puts the spotlight on our open disclosure policy, which has been in place since 2013. It has been a policy of the HSE since 2008 that all instances should be disclosed, which is coincidental timing in terms of this issue, but it is long known that this is not the case and that what we have had is not enough. This was known in 2015 when we questioned the then Minister for Health, Deputy Varadkar, on why there had not been a mandatory duty of candour inserted into medical contracts and why, given the weekly medical negligence claims and legal fees, a failure to disclose was not a criminal offence and so on.

It was obvious in the discussions last year around the Civil Liability (Amendment) Bill that there was a problem with open disclosure. Lest anyone is confused, this is only about indemnifying doctors and nurses. This is not an open disclosure policy, it is legal cover. We made the arguments at the Committee on Health and Fianna Fáil was swayed by those arguments and came on board. What happened next? I got more attention from the HSE than I have got in my life. Over the summer, there were emergency calls and meetings arranged with the chief medical officer, all to tell us that we were wrong about our amendments. We had a meeting with the Department of Health and the HSE in which we asked for the evidence to support their argument and we were told that making open disclosure mandatory would make it less rather than more likely that open disclosure would happen. This was the line put forward by the Department of Health and the chief medical officer, the same line that was given to the then Minister for Health, Deputy Varadkar, when he came before the health committee in 2015 and argued for mandatory disclosure. In my opinion, he genuinely put forward that view. He made the point as a doctor that failing to live up to a duty of candour was the equivalent of a motoring hit-and-run. He was fully signed up to mandatory open disclosure.

The health committee, having heard from several stakeholders which said that mandatory open disclosure was necessary, did not recommend it. What happened? The arguments were made, the science and international evidence was produced and previous Ministers, Fianna Fáil colleagues and others supported mandatory open disclosure, yet behind the scenes the HSE went to work and put out the argument that it was not the best way forward. The HSE can dress it up whatever they like, but at the heart of that dressing up is a fear of litigation. The HSE tells Ministers that this and that cannot be done because it will cost the State money. It is symptomatic of problems in that organisation. It gives me no pleasure to say, "We told you so". We stand over the arguments we made last year. Sadly, if they had been incorporated in the legislation, we would be further down the road and not moving after the horse has bolted.

I am open to a HIQA inquiry in the sense that HIQA is good, but I echo the point that it is limited in its scope to an extent. I think we have to go further. In 1987, the New Zealand Government ordered a full-scale independent judicial inquiry into the deaths of 26 women who died in the 1970s and 1980s from cervical cancer, again a national scandal. This inquiry was an independent inquiry along the lines of the Commission on Nursing in this State, which is what we need if we are to get to the root of this and get to the heart of way in which women's health and reproductive issues are dealt with, or rather are not dealt with, in the State.

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