Alan Kelly (Tipperary, Labour) | Oireachtas source

I will not be able to cover one quarter of the issues I want to talk about in ten minutes. We could have written the first page of the Scally report. It refers to systemic system failure. We all knew that. I am a member of the Joint Committee on Health and the Committee of Public Accounts. Systemic system failures happen because people either make or do not make decisions. Human enterprise is involved. This is not something that happens from on high and we have to find out why it happened. Who made or did not make decisions and who acted in certain ways such that we ended up where we are today? If not for the bravery of Vicky Phelan, we would not be talking about this today. It is incredible and I want to acknowledge her, Stephen Teap, Lorraine Walsh and everyone else. I have spoken to many people on this, many of whom do not want to be named.

I welcome the Scally report and having spoken to Dr. Scally on a number of occasions since its publication, I welcome his frankness. This was a scoping inquiry, not a full report. It is nowhere near being one because the issues are too large and it is not of that scale. It is limited but it is excellent in its findings. The 50 recommendations of the report are the priority for all of us in this House. Everything else is secondary. The 50 recommendations have to be implemented. The move to the HPV vaccine is a priority. The Minister needs to resource the laboratories and the personnel to be able to implement that. He must also implement the resolution that I and my Labour Party colleagues passed in the Dáil to extend vaccination to boys to create herd immunity.

Non-disclosure will be dealt with and has to be a priority. Loss of trust between clinicians and their patients has been spoken about an awful lot. I do not want to dwell on it except to say it was enlightening. It is something on which the medical profession and many different medical representative bodies need to reflect, not just in this area but in a number of other areas too. Many of these clinicians met during this process. This was not known to the public until we pulled out the minutes of colposcopists' meetings that took place in the middle of this crisis. That needs to be investigated. Clinicians were aware that there was a serious issue but there was no urgency. We need to find out why that was the case.

There are structural issues with the HSE. As I stated, this happened because people made or did not make decisions. It has gone beyond a matter of debate that we will have some form of inquiry or investigation. Any investigation should be short, must not get in the way of recommendations and should have tight terms of reference. We need to find out who did what, when, where, why and how with regard to the HSE CervicalCheck and possibly the Minister's Department.

There is a jigsaw for where we are going with regard to cervical cancer. The priorities are the recommendations, HPV, and herd immunity and extending vaccination to boys. That is one component. The second is the review of the slides by the Royal College of Obstetricians and Gynaecologists, which is critical. The third relates to Mr. Justice Meenan's work. I hold the Taoiseach, not the Minister, accountable for this. On more than one occasion, the Taoiseach did not know what he was talking about. He did not know what he was talking about on "Six One News" when he said that the women affected would not have to go through the courts, the laboratories would be chased and they would settle with the women. He was wrong and I knew the second he spoke that he was wrong. He subsequently met Vicky Phelan.

Mr. Justice Meenan's work has two components. The broader component is due in a number of months but his first findings will be in a couple of weeks. I do not believe the judge can achieve a great deal other than making recommendations, which means the Taoiseach has overpromised a second time. I find it almost impossible to envisage a scenario in which women will not end up in the courts again and that is disgraceful. Please bring that message back to the Taoiseach.

The fourth component of the jigsaw is what we need to discuss in the coming weeks as regards investigating who did what, when, where and how in the HSE and other organisations, the issues related to a forum to deal with what clinicians did or did not do and, in particular, the manner in which they behaved. In addition, there are elements related to how contracts were managed with the laboratories.

I am delighted with what Dr. Scally said about the laboratories. I dare say it helps the Minister and all of us in this country in ensuring we have a screening programme. We must all behave responsibly in the future in order to have a screening programme. I welcome that, but we need to ensure there will be an investigation into how the contracts were managed, or not. I will come back to that point.

Before I speak about the laboratories, I wish to deal with one other matter, namely, the commentary over the summer on the purpose of some of the work being done by many of those affected in this country. It almost amounted to revisionism. The view was that their pursuit of justice and their legal rights was, in some way, damaging the future of screening. That insinuation was wrong and affected people who had ensured the matter became public in the first place. As far as I am concerned, such revisionism should be avoided. I know Vicky Phelan, Stephen Teap and Lorraine Walsh and their number one priority is not self-interest. They have families or, in the case of Lorraine, she does not because of what happened. Their number one priority is ensuring screening is available for future generations, my children and everyone else's.

I welcome what the Scally report states about the laboratories, but I have some questions. I am concerned about the manner in which the contracts were managed by the HSE. The laissez-faire manner in which the contracts were managed by the HSE must be investigated. We know of 221 cases. There are accepted errors in some cases. We all know that negligence must be proved, but in some cases we know what happened. Has CervicalCheck or the HSE investigated what happened in these cases? It is such a simple question, but it is so obvious that it does not occur to people. We know of cases, as they are public. As of today, have they been investigated? In any scenario where a public body has such issues, surely it looks at its contracts and investigates what happened in each and every case? Surely, it looks for patterns and examines every detail. I deliberately raise these questions with the Minister.

The new information provided in the Scally report on CPL and outsourcing to other laboratories across the United States is very welcome. No provision was made for this. How did the HSE or CervicalCheck not know it? Who was monitoring the position? Who was not doing his or her job? That is not acceptable. We have had scenarios where the CervicalCheck service was in operation, contracts were in place and we now know outsourcing took place about which CervicalCheck did not know. We now know that there were errors and issuing about how women were dealt with. I am still not sure who in the HSE has been investigating that matter, who has gone through the contracts and whose job it was to look at the contracts and ensure there was quality assurance because there was not. That is a component of an investigation, with who did what, where and when in the HSE, in addition to the other issues I identified. We will need some inquiry to be agreed to. It should be agreed to in the next two weeks consequent on the Minister, me and others meeting patient advocates and those who have been the victims, to whom reference has been made.

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