Colm Burke (Cork North-Central, Fine Gael) | Oireachtas source

It is important in dealing with this debate that we give reassurance to parents because they have gone through a difficult time. When a child needs any kind of surgical procedure, it is always challenging for parents to face into that. Are they making the right decision? Are they getting the right advice? Should they follow through? When they come across a difficulty like this and have to deal with it, they in some cases put the blame on themselves. They should not take any blame for anything that occurred here because they did the best for their child on the basis of the advice given to them. We need to acknowledge the priority that must be given to children who have a medical challenge in their lives, whether it relates to hip operations or any surgical procedure or whether it is cancer care. They must be given priority as regards how we care for them and be given the maximum support and the highest quality of care. Because they are not able to fight their own corner, they rely on us and their parents to fight their corner for them.

It is important in any debate on medical issues to acknowledge the staff in our hospitals: nurses, doctors, care assistants, consultants, porters, management staff, right across the board. Every one of them goes to work in the morning and wants to provide the best possible care to the people they look after. Errors occur but the question is how to prevent those errors from occurring and how to have a system with checks and balances. The objective is to eliminate mistakes and ensure mistakes are not made.

In this case, non-CE marked metal springs were used in the period 2020 to 2022. In the summer of 2023, public concerns were raised about their use and the surgical procedures that were taking place. In October 2023, the then Minister wrote to HIQA regarding serious patient safety issues and the need for an investigation. In the amalgamation of the hospital structure in Dublin into the new national children's hospital, it is interesting to see the changes occurring and the challenges managerial staff, nursing staff and doctors face. Page 28 of the report states:

HIQA found that CHI was experiencing significant organisational and transformational change during the time period of this review - November 2018 to July 2023. Relevant factors at national level which impacted the change included: - the COVID-19 pandemic[...]

- the cyber-attack which occurred across public healthcare IT systems in May 2021 which also impacted CHI significantly

- the continuing uncertainty of the substantial completion date of the National Children’s Hospital having a significant impact on planning and implementation for the organisation, including the recruitment of specialist contract staff and consultants required to commission the National Children’s Hospital.

Those were the challenges they faced at the time and at such a time there is a need to be even more careful and to ensure all checks and balances are in place. The ethics and research committee had not approved the use of the springs.

7 o’clock

The ethics oversight process was in place at CHI Temple Street. It was important to work within the guidelines and with the approval of the ethics committee, but no such approval was given. No formal structure or process was in place to support the surgical multidisciplinary team at CHI Temple Street. The clinical director was not made aware of the intended use of these springs. No contracts were in place to carry out any type of safety or technical checks in respect of what was happening and springs were not ordered, tracked or listed on the business management system. None of that should have occurred. These are major errors that were made because someone decided they did not need to go through all of these processes.

There is a big challenge ahead. When we move to the new children's hospital, we will need to be even more careful that slip-ups are not made and there are no long-term consequences for the people who require care.

In terms of understanding healthcare, it is important to understand the rotational nature of the people working within the system, whether they are trainee nurses who have just started and are trying to acquire the skills, or a doctor who starts off as an intern, SHO, registrar, senior registrar or consultant and is moving around from hospital to hospital because it is part of the training process. It is important that while they are in the training process, if they see something not being properly carried out, they feel they can highlight the issue without being worried about their long-term promotional prospects. One of the things we need to be careful about in the medical system is the fact that people who identify a problem can be afraid to raise it.

We have seen the report of the Health Information and Quality Authority. Once we receive all of the reports, we need to ensure that every possible process is put in place so we do not have a repeat of this situation. Fifty or 60 years ago, procedures were carried out on women in maternity care but it took us 50 years to acknowledge the wrong that was done. Let us make sure in this case that we deal with the issue now and put proper processes in place to ensure it does not happen again at any time in the future.

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