Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)

I welcome the opportunity to update the House on the response under way following publication of the clinical audit into developmental dysplasia of the hip, DDH, surgery on children in CHI and National Orthopaedic Hospital Cappagh, published last Friday, 23 May. This follows on from our debate on 29 April where we said we would revisit this and it is appropriate we continue to work on these issues together in the coming months to address our shared concerns and to move to a place where we have better confidence in the clinical governance and decision-making in certain parts of CHI that have presented repeated difficulties for patients.

Parents and young people themselves will have many questions when they read the report, and the findings of this report will lead to worry and uncertainty for them. Like many Members, I have met and spoken with parents whose children had these surgeries and I know their worry, as do my colleagues in this House. This experience of worry for your child and of being completely in the hands of a clinician, their advice and decisions is one those who have not experienced it perhaps cannot understand, in particular, the depth of concern. In that vein, I respond today and other days to all the issues in CHI we face together in this House as the current Minister for Health but also as the parent of a child in the long-term care of CHI.

I hope the actions we now take will help in that process, although I recognise the volume of cases mean it will be some time before everyone has a resolution to their satisfaction. I am not happy about this but please let me take the House through the actions to be taken, the backdrop against which they will be taken and where we will need to go together for the future.

The actions I am now taking will ensure better improvements: first, in implementing the clinical recommendations of the audit to prioritise patient’s follow-up care; second, in establishing an independent and external expert panel to lead a retrospective review of individual cases to determine the appropriateness of the original decision-making for performing the pelvic osteotomy; and, third, in taking steps to strengthen governance and oversight in CHI as we move to a longer-term perspective. My immediate priority is to ensure there is clinical follow-up and care for patients who have undergone this surgery. This follow-up will be in accordance with best practice and the recommendations of the report.

Deputies know an information line was available over the weekend. This is an information signposting for parents in the first instance. I appreciate this does not answer every question - nor can it - in that effort to try to provide signposting. What parents need and what they will receive is letters from CHI and Cappagh hospital about the arrangements and next steps that individually apply to them and their child and how they will get further information or support. I expect these letters to be accurate and personalised. While Deputies will appreciate I do not sign off on every letter, I assure them I have said to both these institutions that I expect that standard to be there for these letters.

I recognise that the wait for the letter is difficult in itself and I do not want parents getting wrong information of any kind.

I have been informed that clinical follow up to skeletal maturity in CHI Crumlin is already under way for 447 patients. Many of whom, about 200, are almost at skeletal maturity and will likely need just one more appointment. Clinical follow up is also under way for CHI Temple Street and Cappagh patients. These children have been identified and categorised by age. That encompasses approximately 1,800 children, a proportion of whom, 392, as I understand it, are close to skeletal maturity. It is planned that a multidisciplinary team, including physiotherapists and nurse specialists and overseen by a consultant surgeon who is appropriate, will be involved in this clinical review. It is also important to recognise the transition of care for patients who require follow up by adult services will be agreed. A new model of care for all children who have undergone and will undergo these surgeries will be implemented, generally involving review at five, eight and 12 years post operation.

Deputies are already aware that a cross-site pre-operative surgical meeting is already in place since March 2025. We discussed this in April. All children are being discussed at this meeting before they are listed for surgery by any of the services concerned. This, along with contacting parents whose child may be impacted by this audit, were, I am told, the two recommendations the auditor made to CHI when he provided a draft of this report in March. I am told CHI was informed that these were the only two recommendations that were available and definitely would not change, pending the publication of the report.

In respect of a retrospective review, of course what parents will want to know is whether the surgery their child had was appropriately clinically indicated. Patients and parents are entitled to know and there will be retrospective review of their case to determine the indications for surgery - was it needed or how was it in line with standards at the time it was indicated. This is separate from the clinical follow up process. It is a separate and additional process, involving a panel of independent external experts, and it will be established for this purpose. It will not be connected to CHI. This panel will comprise radiologists and paediatric orthopaedic surgeons and will be chaired by an international expert. Professor Deborah McNamara, president of RCSI, has agreed to assist the HSE in establishing the expert panel.

Today I brought a memo to Government to set out the high-level terms of reference for this review. The review will have the following objectives: to provide individualised case reports for each of the cases affected; to provide an overall collated report; to provide expert opinion, insofar as possible, on individual cases of potential implications where it was identified that a procedure was not necessary - I will ensure Deputies have this to hand; to have due regard for the criteria as set out by Mr. Thomas within his report and the criteria being developed by the expert reference group; and to document the final suite of criteria against which the original surgery will be assessed. In conducting this review, the experts will be cognisant of the historic nature of the work and will be aware of confirmation and hindsight bias. The terms of reference cannot be finalised until the review panel is some way in place. I want to make sure they are comfortable with the terms of reference. I have taken it as far as I can and I need the opinion of the expert panel on its terms of reference, as the Deputies will understand. Obviously, parental consent to participate in the review will be required. I suspect parents will be actively seeking this review rather than us asking them to consent to it.

This will take a little time, both to bring together the panel and to complete the reviews. This is a recommendation of the report which we received on Thursday last and published on Friday. I know Deputies across the House have criticised this not already being in place but, as I said in April, I can only go on the detail of the report as it is presented to me. I received the report on Thursday last at 4 p.m. It was published in full, as I said it would be - redacting any personal information, which, as it turned out was not necessary - at 1 p.m. on Friday. The terms of reference and follow-up process are now agreed by Government and the outstanding piece is the independent experts. I assure the House I will move with the same pace and urgency on that matter as I have, I hope, with other matters.

I want to be clear about accountability and governance-response issues. It is correct, as Deputies in the House have already done, to look at the systemic and structural issues we will discuss shortly. However, I want to take a moment to recognise that we are having this series of debates because of the decision-making of individual consultant surgeons, whom the audit and the HIQA report have said were not operating in line with international practice and whose explanations for those operations were not accepted by the auditor. In the HIQA report, we were responding to a series of decisions that a surgeon made that led to them using surgical springs in the bodies of small children. We have to ensure proper clinical governance and accountability. However, I do not want our focus on that to detract from the individual decision-making and individual accountability that is appropriate for the individual surgeons making decisions about small children.

Related to this, on the broader governance issue, I have said a number of times that I am trying look at this question in relation to the broader governance of CHI in a way that enables the functional continuity of CHI, both to respond to the various patient needs and the issues we are discussing, the broader running of the paediatric system and to move us towards opening the new hospital. I want to ensure we see the appropriate governance structure in place to make sure that we have clinical leads who are managing each team, as I said in April after the publication of the HIQA report. I want to make sure every consultant who is employed in the State knows they are not a single fiefdom, that they work within a hospital system, that they are public servants paid by the taxpayer and that they follow rules set out by us in an appropriate governance structure.

I want a culture, as I have said before, where people who see things that are clearly wrong not only can step forward and say that but must step forward and say that and be afforded the appropriate protections. In that vein, I particularly want to thank the whistleblower in this context who brought this information to light. I respect the work the whistleblowers have done in this case, as they have done in other cases. I hope we will work together on this, and I am sure we will, but I am trying to undertake a transformation process in a steady way. However, I do not wish that to be interpreted as ignoring the importance of any of these issues. I am trying to manage this in a steady way.

CHI was established in 2018 under the Act to bring together three historic hospitals under a single roof. Differences and cultural problems manifested themselves in different ways over the period but the concept of a single paediatric system is now well settled, even if sometimes some people need a little reminding. The board is an unusual construct where four members, as I have said before, are appointed by the Minister. Eight are appointed by the board itself, coming from the nominations of the old historic entities that were brought together to CHI. The board itself appoints the chair. There have been members of the board dating back to 2018, including until recently the chair and there are other members appointed this year or last, so there are two very different sets of institutional memory and institutional experience.

Deputies will be aware that in April the chair stepped down and since then a total of four other members have stepped down, all of whom were appointed in 2018, I believe. This afternoon I referenced on radio that I had received three resignations this morning but I did not reference, and of course should have, that a fourth had stood down last week. My apologies for my oversight in that regard. It was certainly not intentional. I thank them for their contribution. We have to think about public appointments and public service generally. We are asking these board members, for CHI or other entities, to serve the public interest. They are not professional clinicians but they are people who are broadly committed to public service. I am not by any means excusing individual actions. I am simply saying that it is in all of our interests that people continue to want to perform public service. That is why I am trying to separate out some of the issues from the decisions of individual clinicians. These things should not be conflated. However, I think it is true, as I have said in different ways before, that it was important in the case of CHI that while the experience of the board setting up in 2018 had very serious and difficult work to do, it is now appropriate that their experience is brought to a point where a refresh is appropriate. I take the next steps with the following purpose.

I have moved immediately to strengthen governance and oversight structures at CHI and Cappagh. This will be done by the appointment of two members of the HSE board to the board of CHI. I have already done this. That was before I received these additional resignations. I now have additional vacancies, which I will reflect on. Regarding Cappagh, I have also asked the HSE CEO, Bernard Gloster, to consider the implications of the audit for Cappagh and its oversight of paediatric surgery conducted at the hospital. The CEO has agreed to do that and to respond in the coming days.

At operational level, there will be a strengthening of the service level agreement between CHI and the HSE to strengthen operational oversight, and increased involvement and support from the Dublin and midlands region regional executive officer and senior management. That is designed to support the new CEO, Lucy Nugent, in CHI and enable her to continue with the transformation programme she has begun. Ms Nugent has been in post just since February and is in the process of establishing a new executive team around her to lead this next stage for CHI in the way we want to see it done. She reports to the board and needs a functional board to be able to function.

7 o’clock

It is in nobody's interests to move things too rapidly. There does need to be a functional board, although it is clear that I want it to move in a particular direction. My appointments to date have signalled that direction.

I have said, as I referenced previously in this House, for example, on 9 April, the day after the publication of the HIQA report, that I am open to looking at the governance of CHI in the round. I said that we need to have a functional system to be able to work towards the opening of the national children's hospital. I also said that I am open to looking at everything in the round, but that I would like to receive the other two reports first. Some weeks later, it is now clear that we have a very different board to the one that was there when I took office and, much more importantly, when these events occurred. Second, I have clearly said that I want to see an appropriate clinical governance structure. What this means is that consultants work to a clinical governance structure from which they take direction and to which they are accountable.

Earlier today, I met with the Attorney General to discuss my next steps in relation to the board, clinical governance structures, broader governance issues and how CHI interfaces with the HSE, recognising that the HSE funds CHI. I will take a steady approach to this. I welcome all perspectives from Members of this House about the desirable outcome and the steps to get there while enabling the continued functioning of CHI.

I want to facilitate the Minister of State, Deputy Murnane O'Connor, in contributing to the debate. While we are discussing hip dysplasia, it is very important that I update the House on an internal CHI report that was covered in the media on Sunday. That report was provided by CHI to the CEO of the HSE on Monday, 26 May, and I also received a copy from the HSE on the same day. Yesterday evening, I wrote to the board of CHI requesting a full response to the report. I wrote a detailed letter asking specific questions and I reserve the right to write further letters. I need to receive the response but, on its receipt, my officials will follow up to address outstanding risks or concerns where they still exist.

In addition, the CEO of the HSE is commissioning an audit of governance and equity in patient access and waiting list management at CHI. The audit aims to assess governance and equity in access to care, especially regarding the balance between public and private patient management. I will consider further responses to the issues around waiting list management and the NTPF raised in the report. I have also asked the NTPF for its perspective. We are mandating centralised referral to all CHI surgical services in order that all GP referrals will be processed via a central system, enhancing transparency, equity and efficiency, with the aim of ensuring patients are cared for based on clinical need and to increase effective management of waiting lists.

I tried to leave as much time as possible to take questions throughout. We will speak about this matter again very shortly at the Oireachtas committee.

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