Dan Neville (Limerick West, Fine Gael)
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I thank the Ceann Comhairle for allowing me to raise the important matter of the review into the death of Róisín Ruddle, Kilmacow, Kilfinny, Adare. I am a fellow parishioner of the Ruddle family and have known Róisín's mother and father, grandfather and great-grandfather, who have been highly respected members of our community. I thank the Ruddle family for their co-operation with the review into the sad case of the death of their daughter, Róisín, and sympathise with Gerard and Helen. I commend the regional health authority, its staff and the staff of Our Lady's Hospital.

On 27 March 2003 Róisín Ruddle was placed on the elective cardiac surgery list of Our Lady's Hospital for insertion of a Glenn shunt. Her surgery was scheduled for 30 June 2003. Róisín was admitted to Our Lady's Hospital on 25 June 2003 for her pre-operative investigations and discharged home on 26 June. She was admitted on Sunday, 29 June in preparation for her planned surgery the following day. On Monday, 30 June, Róisín's operation was deferred because there was no staffed intensive care bed available for her following her surgery. Róisín and her parents left the hospital at approximately 12 noon on 30 June and returned home.

Róisín died at home in the early hours of Tuesday, 1 July. She was due to undergo the Glenn shunt procedure on 30 June. This procedure was a palliative operation which was part of a staged strategy in the management of Róisín's cardiac condition. She underwent the normal pre-operative investigations as I have stated. On 30 June her surgery was deferred because no staffed intensive care bed was available.

The autopsy indicated that Róisín's death was due to acute cardio-respiratory failure associated with the presumed development of a cardiac arrhythmis. This view was supported by the medical opinion presented in the course of the review. If the Glenn shunt procedure had gone ahead as planned on 30 June, it would most likely have improved Róisín's oxygen saturation and this may have reduced the likelihood of her condition. Nevertheless, it is the view of the panel that if Róisín's operation had gone ahead as planned on 30 June, the likelihood of her survival would have been greater.

Given the centrality of the ICU to the operation of Our Lady's Hospital as a whole, the shortage of nurses to staff the unit does not appear, according to the review, to have been seen by hospital management at the time as a prior issue warranting significant management attention. From the evidence presented, it is clear that the problems relating to the recruitment and retention of specialist nursing staff were considered matters to be addressed solely by the nursing director and her staff. Although aware of the problems, there is no evidence that hospital management or the committee of management gave any active support, other than the approval of financial resources, to helping the director of nursing with the problem of devising initiatives that were clearly needed to address the recruitment issue that is central to the report and to this highly critical area of the hospital's activities.

It is the opinion of the panel that insufficient focus was placed by Our Lady's Hospital management and the committee of management on the resolution of this issue. As a consequence, there was a lack of urgency in applying and distributing available resources for resolving the problem. The panel pointed out that despite significant efforts made by the staff, the difficulty arises regarding the area of nursing. The fundamental reason for the deferral of Róisín's surgery is clearly stated by the panel. It was due to the inability of Our Lady's Hospital to recruit or retain sufficient experienced ICU nursing staff to support the available ICU beds. Among the factors contributing to the shortage of paediatric ICU nurses was a change in the system of nurse education in the mid-1990s. It was a fundamental managerial planning issue that when such changes are considered by the Department and the Minister, a planned approach should be taken to ensure that these problems do not arise.

I will raise the issue of the development and investment in Our Lady's Hospital on a future occasion. I am amazed that despite the difficulties with recruitment, the hospital does not have a recruitment website. The panel recommends such a website.

Seán Power (Kildare South, Fianna Fail)
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The report of the panel reviewing the events surrounding the death of Róisín Ruddle was published on the Department's website earlier today. The report prepared by the former Eastern Regional Health Board in July 2003 has also been published. Copies of the report were made available to Róisín's family and to Our Lady's Hospital in recent days.

I wish first of all to express my sympathy to Róisín's parents and to her extended family. They have been through extremely difficult times in the past, and the publication of this report will no doubt recall for them all the trauma of those times. Our thoughts are with them today. While it is appropriate for the House to discuss the matter, I know that our words will probably ring hollow with Róisín's family at this time.

On behalf of the Tánaiste, I thank the review panel for completing a very thorough examination of the issues that have arisen in this case. The principal finding in the review panel's report was that if Róisín's operation had gone ahead as planned on 30 June 2003, the likelihood of her survival would have been greater and that the fundamental reason behind the deferral of Róisín's surgery was the inability of Our Lady's Hospital to recruit or retain sufficient experienced nursing staff to support the available ICU beds. The Tánaiste recently met the hospital's chief executive and the director of nursing and they assured her that key recommendations in the report have been acted upon.

For example, in September 2004 the hospital assigned full-time responsibility for the recruitment and retention of specialised paediatric nurses to its most senior assistant director of nursing. A clinical bed manager was appointed in August 2004 to ensure the efficient and effective use of beds and cots in accordance with international best practice. The hospital has already established links in relation to cardiology and cardiothoracic surgery with a number of institutions outside of the country, including Great Ormond Street Children's Hospital.

The chief executive also assured the Tánaiste that the other recommendations in the report will receive the hospital's urgent attention. The Tánaiste expects the hospital's committee of management, the hospital management and the hospital staff to ensure that the issues relating to the hospital's internal organisation are fully addressed as a matter of urgency.

The reason for the deferral of Róisín's surgery on 30 June 2003 was that there was no staffed intensive care bed available in the intensive care unit to accommodate her post-operatively.

The intensive care unit at Our Lady's Hospital has a physical capacity of 21 fully-equipped beds, divided into two units, but has never been in a position to open all the 21 beds due to the lack of specialised nursing staff. In June 2003, the unit as a whole was staffed for between 14 and 16 beds, depending on the casemix between intensive care and high dependency patients. Patients requiring intensive care are nursed on the basis of one nurse per patient; patients requiring high dependency care are nursed on the basis of one nurse per two patients.

The review panel's report notes that, despite significant efforts made by Our Lady's Hospital in more recent times, the hospital is still not in a position to staff its full complement of ICU beds. The review panel's report points out that there is an international shortage of paediatric ICU nurses. In recent times, Our Lady's Hospital has, with the support of the Health Service Executive and my Department, embarked on a comprehensive strategy to recruit and retain nurses for its ICU, including overseas recruitment campaigns in Bahrain, the Philippines and Poland as well as the United Kingdom. The hospital also targets post-registration paediatric nursing students to encourage them to work in ICU.

While the hospital has had some success in recruiting nurses into its ICU, this recruitment has been offset by many of the nurses leaving the unit for various reasons. Many of the nurses working in the ICU are from overseas and some choose to return home or to work in other countries. Others leave on promotion, while others find that the stress of working in such intensive conditions takes its toll.

The hospital has taken many initiatives in an attempt to retain staff, including the introduction of family-friendly work policies and a self-rostering system for its ICU nursing staff which allows the nurse to choose his or her own working hours. The hospital also offers extensive educational opportunities for nurses and provides free accommodation to all non-national nurses for the first eight weeks of their adaptation period.

Among the factors contributing to the shortage of paediatric ICU nurses in this country was a change in the system of nurse education in the mid-1990s. Since 1996, the only route to becoming a children's nurse is to pursue a post-registration higher diploma programme over 18 months. It currently takes four years training to obtain registration as a general nurse, which means it takes a minimum of 5.5 years to qualify as a children's nurse. If the nurse then wishes to qualify as a specialist paediatric ICU nurse, he or she must first obtain a minimum of six months work experience in paediatric ICU and then complete a further higher diploma in paediatric critical care over one year full time or two years part time. It currently, therefore, takes a minimum of seven years to become a fully-trained paediatric ICU nurse. In my opinion, this is too long.

One of the review panel report's recommendations is that the overall training period required to become a fully-qualified children's ICU nurse be re-examined. The expert group on midwifery and children's nursing education has recently reported to the Tánaiste. One of its recommendations, the introduction of a direct entry undergraduate programme for combined children's-general nursing, lasting 4.5 years, must be implemented. We also need to reduce the length of the existing post-registration programme for qualification as a children's nurse. These measures will reduce the time taken to qualify as a children's nurse and should increase the numbers coming through the system.

The Tánaiste will shortly announce how the report of the expert group on midwifery and children's nursing education can best be implemented. She welcomes the fact that the hospital has established links with similar institutions outside of the country and would encourage them to explore this option for courses in specialist and expert practice.

I assure the parents and extended family of Róisín Ruddle that every possible measure will be taken to ensure that all the intensive care beds in Our Lady's Hospital are staffed and available to those children who require access to them.