Richard O'Donoghue (Limerick County, Independent) | Oireachtas source

I hope the media are listening to this. I would like the people of Ireland to know what happens following a serious incident or death in a HSE hospital. If someone is unfortunate enough to be injured or if a loved one is injured or, worse, dies under the care of a HSE hospital, this is what happens afterwards. I ask the Minister to give me his attention. A member of staff who has witnessed the incident is supposed to electronically record it locally in the hospital through a system called Q-Pulse. A line manager is then supposed to investigate the incident and speak to witnesses. Details of a serious incident are to be reported to the national incident management system in the State Claims Agency. I have discovered that staff in the HSE often record incidents locally on Q-Pulse but serious incidents are not always reported nationally. Therefore, no national record is kept of incidents related to a certain Department or member of HSE staff in a particular hospital. This leads to the safety of the public being seriously compromised as opportunities are missed to prevent future incidents.

I found an article on the Internet written by a former consultant in University Hospital Limerick, UHL. He refers to 140 incidents he recorded on Q-Pulse in UHL that were never followed up by management. We now have 70 medical professionals who have also stated they have reported incidents in hospitals and nothing was done. This is what the public needs to know. The HSE jointly manages the national incident management system members in conjunction with the State Claims Agency. The HSE is the owner of the national incident management system healthcare data and related patient safety services user incidents. The State Claims Agency has no regulatory function and does not have legal powers to impose sanctions.

It might be decided by the HSE that an independent investigation should be carried out in a serious incident but the investigation team will be made up of past and present HSE employees and will sometimes include a member of staff from the same hospital. The HSE investigation report is then given to the coroner to refer to if there is an inquest into a death. Those who are not happy with how an incident has been investigated can seek help from HIQA but, again, it is made up mostly of past and present HSE employees. A doctor involved in a serious incident may be reported to the Irish Medical Council. Its members are mostly past and present HSE employees.

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