Dáil debates

Wednesday, 8 March 2006

Lourdes Hospital Inquiry: Statements.

 

12:00 pm

Photo of Mary HarneyMary Harney (Tánaiste; Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
Link to this: Individually | In context

The Lourdes Hospital inquiry is a body blow to us all. It is painful to read, it is hard to believe and it is shameful and distressing. It is more akin to a novel set in the dark early part of the last century than the story of the enlightened, successful, confident country we live in.

To the women who were the victims, this report is their story. It is the story of how the health system failed them and how it continued to fail them. It is the story of women robbed of their ability to bear children. For 44 women it is the story of a deliberate attempt to compound that failure by denying them justice.

For centuries, the maxim "first, do no harm" has been the very starting point of medical ethics. Yet, over many years at this hospital, this first basic ethical test was violated, with tragic consequences. I want to thank Patient Focus, the group which represents many of the former patients of Dr. Neary, for its co-operation with the inquiry which must have been personally very difficult. Once again I express my sincere regret to these women and their families for the pain and the loss inflicted on them.

Judge Maureen Harding Clark and her team have conveyed this difficult story through this powerful report. Perhaps the greatest compliment to the achievements of the inquiry team is the universal comment that this is a fair report. I thank all of the team for the great service it has done. In the future this report will be seen as a catalyst for reform in the health services, an essential read for every student of medicine. Since the publication of the Our Lady of Lourdes Hospital inquiry report last week, I have met Patient Focus, the medical board and management team of the hospital, the Medical Council and representatives from the National Hospitals Office of the Health Service Executive. It is fair to say that this report has had a profound effect on everyone. There is a sense of hurt, shock, outrage and regret. We need to harness these emotions in a productive and positive way. We will take the findings of the Our Lady of Lourdes hospital inquiry and implement them one by one in a manner that bears testament to the private and public outrage.

To do this we need the support and co-operation of all players in the health system. The facts revealed by the report are stark. An isolated hospital or isolated practitioner breeds ignorance and puts lives at risk. We have seen how these backward practices ruined lives in Drogheda. There must be a process of outcome review by peers. Information must not only be available but must be analysed, questioned, compared and reviewed.

To this end I am pleased to announce the setting up of the national perinatal epidemiology centre in Cork University Hospital which will be up and running in the autumn of this year. The centre will cost €630,000 in a full year to staff. This means that every time a mother gives birth, the important interventions, good outcomes and complications will be recorded and analysed at a national specialist centre. Unusual trends will be easily and quickly observed and, most importantly, acted on. The centre has been designed based on models from Australia and its immediate priorities are to devise a single identical maternity chart for every maternity hospital in the country. This is the first very important step in re-establishing trust and ensuring that services to mothers and their babies born here are based on the best possible research.

One of the issues I discussed last week with Patient Focus was redress for the women involved. As a first step, the Government yesterday agreed that Judge Harding Clark should be asked to advise on an appropriate scheme of redress arising from the findings of her report. We are pleased she has agreed to do so. She will also advise on the cost of such a scheme and a mechanism for ensuring the maximum recoupment of such costs from wrongdoers and indemnifiers. Judge Harding Clark has the highest confidence of everyone involved and is the best person to advise the Government on this matter. She will commence her work immediately and will bring her proposals to me as soon as possible.

I will not attempt to summarise the report for the House. I am sure Deputies have read it in its entirety, as it fully deserves. I urge everyone concerned with our health services and the wider public to do so also. As Judge Harding Clark states, many aspects of the report that are "truly shocking" while others still seem inexplicable and others are simply outrageous and leave us angry.

Beyond the failings of medical practice and reporting, what was particularly outrageous was the interference with and removal of personal medical files of the women affected. It is chilling to read that the inquiry found that in 44 cases, obstetric hysterectomy records for the period 1974 to 1998 are missing and were intentionally and unlawfully removed from the hospital. In 40 of the 44 cases the birth registers are also missing. This is not explained by medical practice and culture in times past but relates to cases up to eight years ago. It was an appalling theft of the key to the truth from the same women who had been robbed of their fertility. This is unfinished business and I earnestly hope the Garda can bring the perpetrators to justice. I believe Judge Harding Clark's report will be helpful in that matter.

The report highlighted the urgent need for change and reform in our hospitals and clinical governance. Some of the lessons it captures are that any isolated institution which fails to have in place a process of outcome review by peers and benchmark comparators can produce a similar outcome to that which occurred in Our Lady of Lourdes Hospital; support systems must be in place to conduct regular and obligatory audits; there must be mandatory continuing professional development and skills assessment at all levels of health care; staff need to attend updating of skills and methods programmes and should be able to recognise that procedures change in accordance with evidence-based research; and outmoded and unnecessary practices should be recognised as such and changed as soon as information is available.

The recommendations in the report underline the importance of the policies and actions already being taken in three key areas: the new medical practitioners Bill which I hope, subject to Government approval, to bring to the House later this year; the new contract for hospital consultants which is urgently needed for the recruitment of hundreds more consultants; and changes in management systems and quality assurance within hospitals.

Patient safety in hospitals should be as rigorous as passenger safety in airlines. This must mean a sea-change in culture, as it did in the airline industry. It will mean a culture of openness and preparedness to acknowledge errors and an ability to analyse clinical practice in an environment which does not resort to blame and recrimination. Blame-free reporting is vital, as is analysis of the full facts of events. Most important of all is implementing the lessons learned to achieve constant improvement in patient safety and outcomes. This involves much more than so-called whistleblowing. It is a systematic, continuous and open approach to error reporting and correction involving everyone in the health care setting. It entails a rigorous process of audit, peer review and external evaluation and is the only way to achieve maximum patient safety.

The culture will change, not simply in the degree of deference to be shown to consultants or the personal attitude of individual consultants. Consultants are no different from anyone else. They respond to the powers and responsibilities, incentives and penalties and the individuality and teamwork of the system in which they work. This is the reason the only adequate response to this report is systemic reform and change.

The cornerstone of legislation on medical practice is the Medical Practitioners Act 1978 which provides for the Medical Council to regulate the medical profession. The Act has been amended at various times in the past 28 years and a complete overhaul and replacement for it is being prepared. Work on the new medical practitioners Bill is well advanced and I intend to make available the heads of Bill to interested stakeholders, including Members, as soon as possible. All stakeholders will have the opportunity to comment to assist in the drafting of the Bill proper, which the Government intends to publish later in the year.

The recommendations of Judge Harding Clark's report will be addressed in the Bill in a variety of ways. The Bill will underline the Medical Council's role as the body in this State which acts to protect the public by way of regulation of the medical profession. It will introduce more streamlined and transparent procedures for the processing of complaints and modernise registration processes to allow for flexibility where required. It will integrate registration, education and training, ongoing competence and fitness to practise processes and clearly define the responsibilities of the council in the education and training of medical practitioners. It will also provide, for the first time, a legal framework for the Medical Council's implementation and administration of a system of competence assurance. It is intended that the new legislation will make continuing professional development and education compulsory for medical practitioners.

The purpose of the Medical Council is not only to provide a registration service for medical practitioners. It must also be seen as the competent authority for dealing with serious allegations of professional misconduct. Patients require assurances that their interests are paramount and override any sectional interest. For this reason, I believe that any self-regulating professional organisation should have a majority of non-members on its governing board and I will propose this approach for the Medical Council.

The new medical practitioners legislation will be complemented by the Health and Social Care Professionals Act and other forthcoming legislation governing nurses, midwives, pharmacists and dentists. All this legislation will have a common purpose of ensuring robust governance, clarity of procedures and formal systems of accountability which are aimed at the protection of the patient while at the same time recognising the need for due process when processing allegations against health care professionals.

The Lourdes hospital inquiry report has affirmed the approach being pursued by the Government and Health Service Executive in the negotiation of a new contract for hospital consultants. The necessity for improvements in team working by consultants is clear. The report reinforces our proposals on the contract regarding the need for clear clinical leadership, which will ensure that individual clinical practice is in line with acceptable standards of practice. In addition, the need for a much more rigorous audit of consultant activity is beyond question.

The report also highlights the necessity to have clear responsibility for the training of non-consultant hospital doctors. The Fottrell and Buttimer reports and the new contracts proposed for non-consultant hospital doctors show a clear pathway for the education, training and support of doctors in the Irish health care system throughout their careers.

Clinical governance is about more than clinicians. Effective systems of clinical governance are vital to ensure quality care for patients. These systems need constant review. Previously, we have had very weak clinical governance and oversight in our health system. We need to identify and tackle the weaknesses that exist in every part of the health system, be they regulatory, governance, organisational, managerial or clinical. It is my intention to come to Government presently with proposals to establish a mechanism to ensure that, in particular, clinical governance arrangements are strengthened throughout the health system and not only in the regulation of medical practitioners. In a further step towards quality assurance for patients, the Government yesterday approved the publication for consultation of the heads of the Bill providing for the establishment of the health information and quality authority, HIQA, on a statutory basis. HIQA will set standards and will have powers to investigate most services provided by or on behalf of the HSE.

This report is a call to action. It is a call on everyone involved in health care to embrace change and to take responsibility for a new system that makes patient safety the first and irreducible standard of care. I believe the Medical Council is ready for change, as are many consultants, hospital medical boards, managers and nurses and midwives in the frontline of care. The Government will not be found wanting in its response to Judge Clark's recommendations on a redress scheme, in legislation on clinical standards and medical practice and in the new hospital consultants' contract. We will also bring forward systematic clinical governance to ensure patient safety and quality care.

I believe that in the Oireachtas, as in the country, there is a palpable determination to do all we can to prevent this ever happening again. In this House, we are aware of our differences but we are also aware of our responsibilities, including the responsibility to legislate effectively on grave matters that affect the safety and well-being of the entire population. We will discharge that responsibility; we owe nothing less to the women referred to in this report.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
Link to this: Individually | In context

The Government has been found wanting in terms of the recommendations of this report, many of which have been promised on many occasions but were never implemented. There will be no cultural change in the medical services unless we make it happen. As a doctor, I am disgusted by what I read in the report about the actions of one doctor and the support given to him by other consultants. Doctor Neary's reign of destruction was allowed to continue due to complicity, misplaced loyalty and fears of authority and the possible consequences for anyone who spoke out. Doctors, nurses, administrators and members of the Medical Missionaries of Mary can be implicated in Dr. Neary's actions at Our Lady of Lourdes Hospital. Not all are as guilty as the media alleges, however. Many areas of the Irish health services continue to be extremely stressful environments which inspire loyalty among colleagues. Unfortunately, the isolation and the bunker mentality noted in the report is a consequence of not applying checks and balances to the system. The Government, particularly the Tánaiste, has a role to play in this matter.

The leadership of the hospital, from consultants and nuns to management, was completely inadequate, as is the management systems in many other parts of the health services. Consultants in the Irish health services hold as much power today as they did when Dr. Neary ran the maternity department in Our Lady of Lourdes Hospital.

The victims of this story are the women whose uteri were removed because Dr. Neary went unsupervised for too long. It is only right that the Tánaiste has committed herself to making sure that compensation will be paid promptly. If other issues arise regarding justice for these women, these must also be addressed without delay.

The issue of who was responsible for these events must be discussed. Having worked in eight different hospitals, I do not consider junior doctors as the villains. I was never in a position to stand up to the all-powerful consultants who dictated career pathways. Nobody questioned them because careers could be finished by doing so. These consultants continue to control the careers of junior doctors, be they Irish or non-national.

However, consultants from outside the hospital and weak management systems exacerbated the problem. Dr. Neary may be discredited as a consultant but the Tánaiste had little to say with regard to the other consultants mentioned in the report. We know that the three consultants who went to Drogheda to investigate Dr. Neary provided the first report on his activities. I want to know what the Tánaiste has to say on the implications of that investigation. The same consultants who accepted restrictions on their terms of reference felt fully qualified to pronounce Dr. Neary safe. They found no grounds to suspend Dr. Neary or to place any restrictions on his public or private practice.

The reference to "public or private" reveals that money was an important aspect of this matter. If Dr. Neary was suspended, his public salary would continue to be paid but his private practice would be affected and legal pressure was applied on the administration of the hospital and the former North Eastern Health Board in that regard. The consultants who came from Dublin were complicit in this, as is evident from the fact that eight of the 17 cases they were asked to review were excluded because Dr. Neary informed them that these were consensual hysterectomies. I do not think the consultants were satisfied that this was the case. Imagine a criminal demanding to see the evidence against him or her and deciding whether it should be presented in court. These terms of reference were nonsensical but were accepted by somebody.

The report of the Lourdes inquiry implies that legal pressure was placed on the then North Eastern Health Board before the review of the Institute of Obstetricians and Gynaecologists. The Tánaiste never clearly stated who was responsible for that review. Did the Medical Defence Union call in the three consultants? It is vital that we know that answer. The consultants involved have expressed regret for allowing compassion and collegiality to come before due process. Was this misplaced loyalty or does it smack of incredible arrogance? Issues of criminal negligence also arise. These consultants could have obviated the need for an inquiry and if the Tánaiste is serious in her claims for self-regulation or on changes to the Medical Practitioners Acts, she must speak to this issue. Self-regulation is important but it must not follow the practice in this case.

Before the three consultants became involved, Dr. Ambrose McLoughlin discovered that the incidence of peripartum hysterectomy in Our Lady of Lourdes Hospital was out of line. He was supported in this by the medical director at the hospital and the director of nursing, who had examined a number charts and found major problems. To the best of my knowledge, the three consultants from Dublin never consulted Dr. McLoughlin and his colleagues, even though they were in charge of the hospital. We need more clarity on this because I am aware of the power held by some in the health services. The events at Our Lady of Lourdes Hospital could recur elsewhere and fine words will not correct the problems. We need something more robust. Look at what happens when a doctor in the UK, Dr. Michael Maresh, reads the same nine charts that the three consultants read. He believed "Dr. Neary's clinical judgement to be significantly impaired and that women appeared to be put at risk". This line should be compared to the other nonsense written by the three other consultants. They were more concerned about image, private practice and not looking bad. This should be highlighted much more.

Other consultants were involved who attempted to hijack the investigation which was going on. I researched this, going back on media reports on the time this came out. Marches and protests were organised, and other consultants were involved, using their power to stop this going ahead. I believe it could happen again.

The only factor which endears me to this issue is the way some of my colleagues carried on. People such as Professor Bonner, Dr. Patricia Crowley in the Coombe Hospital, Dr. Jim Kiely of the Department of Health and Children, and Dr. Finbar Lennon acted in the appropriate manner as doctors protecting their patients. They deserve full respect for that, and they are not the only ones. Surprisingly, politicians across parties do not come out too badly either. These politicians include Deputies O'Dowd, Crawford, Ó Caoláin and even Deputy Noel Dempsey. All emerged quite well when the background scenes are considered.

The real heroes in this were the midwives who were prepared to put their careers on the line and who stood up to incredible pressure. Some midwives and administrators in the hospital genuinely did not know what was going on there, and some had lost control of their lateral thinking. They may have been carried away on what was occurring inside. Individuals in the hospital were prepared to do significant work for patients, be they politicians, doctors or nurses.

We must support these people, and not just with fine words. Every recommendation discussed by the Tánaiste and those put forward by Judge Harding Clarke has been Government policy in some form for the past five years, but without implementation. They have not moved forward. The role of legislators and Government in this has been disgraceful. One can see that many practices such as clinical audit, peer review and risk management have not been implemented. Competence assurance is still in the planning stage, and no resources have been given to these issues for the past five years. The system is still a complete mess. There is no information dispersal on the health care services.

With regard to legislation, we know about the Medical Council and we have been calling for it for the past seven years. The Tánaiste is telling us it will arise this year. The Minister for Enterprise, Trade and Employment, Deputy Martin, last night spoke on the whistleblowers legislation, stating he would deal with major legislation sector by sector. The Tánaiste has promised both the Health Information and Quality Authority and new medical practitioners legislation, due to come out in the next couple of months, from the Department of Health and Children. Will we see a section covering whistleblowers in the legislation?

Photo of Mary HarneyMary Harney (Tánaiste; Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
Link to this: Individually | In context

Yes.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
Link to this: Individually | In context

Is Deputy Martin and the rest of the Government paying lip service to what is happening?

There is a need for robust management within the health service. People such as Dr. Ambrose McLoughlin and Dr. Finbar Lennon put their necks on the line to get this through. That same robust management does not exist right across the health care service. Management is still intimidated by consultants and other vested interests within the health services, and the Tánaiste knows this. I would like to see her being more proactive in discussing this, and not being wishy-washy about a new consultants' contract or arguing that new management systems will be introduced.

The Tánaiste knows there was a case in this country where a consultant was pushed out of a hospital as other consultants in the hospital were not happy with the amount of work he was doing. He was working too well and fast, eating into the private practice of other consultants. Through management, those other consultants were able to get the doctor pushed out of the hospital. They bullied and intimidated weak and pathetic management into protecting their interest. The Tánaiste is aware of this case and she has done nothing about it.

I could quote other cases where we have seen bad management, and where management has been intimidated into being at the beck and call of individuals, not for the best patient care but for their own interests. The Department of Health and Children and the Government has shown no concern about this. We will be pushing these issues on this side of the House. This report, like the Ferns Report and others which condemn Government policy and which have come out in the past few years, will merely fall to one side. The Government remains apathetic on the issues. We in the Opposition will not let that happen in this case, as this is far too important.

The Department of Health and Children has a disastrous record on legislation in the past eight years. There has been a poor amount of legislation emanating from the Department in that period. We should be more proactive with regard to employing consultants in the future, and what types of checks and balances are being introduced. We must support good consultants, as there is a significant number of good consultants working every day on behalf of patients. However, people can go bad in this system as there is nothing to hold people back. This needs to change dramatically.

The Tánaiste should propose a proper patient safety authority. This would not be a subsection of a subsection of HIQA or an expectation of the Medical Council or HSE complaints procedure. I would not like to rely on the HSE complaints procedure to sort me out if I was a man on the street with a problem with the health services. We in the Oireachtas, directly responsible to the whole country, have a disastrous flow of information coming to us from the HSE. I believe this to be deliberate.

The Freedom of Information Act, the HSE and many parts of the health services are being treated in a way that aims to stop the flow of information. The Government has been made less accountable to the people, and transparency has been knocked out of the system. It will come as no surprise to me if there are future cock-ups like this. Processes are being developed to cover the Government's inadequacies. The Tánaiste should face up to this truth.

I have asked a question on a number of occasions with regard to Comhairle na nOspidéal. It has been responsible for hiring consultants, but it is being subsumed into the HSE. There is no clear idea of what the body is doing and who is employing consultants. As it is run by consultants, who make decisions on other consultants and where jobs will be, the system behind it has been abused. It has been manipulated in a way to ensure favoured people get favoured jobs in certain hospitals. It is a fact of life which I am sure the Tánaiste knows about.

What has the Tánaiste done with regard to the reform of the HSE to ensure this does not happen in the future, or to prevent the ways and means of stopping it? Nothing has been done, and it is all lip service to the concerns we are all considering in the health care services. Action is not being taken.

Some of the recommendations relating to clinical audit, competence assurance and peer review were included in the Hanly report. That report was a bit of a mess, as it was again written by a small cohort with its own interest at heart. I pointed this out in the past, but the Tánaiste took no notice. All the issues surrounding the vital matters of competence assurance, peer review and moving forward to genuinely protecting patients have been in every Government strategy since it entered power. However, only lip service has been paid to them. The only time a hospital can put resources into these issues is when something goes wrong. That is no way to treat our health services, and it is absolutely disgraceful.

Photo of Mary HarneyMary Harney (Tánaiste; Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
Link to this: Individually | In context

That was in the past. I assure the Deputy that is not going on now.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
Link to this: Individually | In context

Everything is in the past with this Government and everything else is in the future. When the Cabinet was reshuffled in September 2004 I thought we had a change of Government because people were running around stating that everything was going to change. There have been more pronouncements about what will happen in future than action taken in the past five years. That is playing politics with people's lives.

The Government has not proven its commitment to delivering what it is meant to. This issue concerns patient safety, competence assurance, looking after patients and training staff, be they nurses, physiotherapists, doctors, junior doctors or consultants. We are discussing these matters today, not the delivery of services or their future reorganisation. The Tánaiste has done nothing for these anyway. We are discussing the protection of the patient, and the Tánaiste's record on this has been abysmal. In the next eight or nine months the Government will publish the medical practitioners Bill, the Health Information and Quality Authority legislation and even a pharmacy Bill or a nurses Bill. Given the pace of change, I cannot believe that legislation will be enacted before the next general election. In 2005 the only health legislation brought forward was for the establishment of the HSE and two amendments. One concerned the registration of deeds, the other the illegal nursing home charges which had first to go to the Supreme Court. That is a poor return from the Department of Health and Children in terms of legislation.

Photo of Mary HarneyMary Harney (Tánaiste; Minister, Department of Health and Children; Dublin Mid West, Progressive Democrats)
Link to this: Individually | In context

The Deputy is wrong. There was the Health and Social Care Professionals Bill and the Irish Medicines Board legislation, among others.

Photo of Liam TwomeyLiam Twomey (Wexford, Fine Gael)
Link to this: Individually | In context

Some of those were completed this year. How can we expect confidence to be restored?

I hope the Government will take some of these points on board. We need more clarity on the content of the report, although Judge Harding Clark did a very good job. She highlighted many things that happened in the past and made proposals for the future.

Concerns remain over the theft of the charts, which the Garda must pursue, and the authorisation of the consultants to enter the hospital. They seemed to act as if they owned the hospital and they made no contact with management. I wish to know who sent them in. Was it the Medical Defence Union? On what basis did they operate? It is vital this is cleared up because it shows the power the consultants had to dictate matters.

As with the example I gave to the Tánaiste, which only happened within the past 18 months, and I am sure there are others, these things are happening in the health service because of a lack of robust management. What the Tánaiste regards as reform of the health service is no such thing. There is nothing about the HSE that gives me confidence that the health service has been genuinely reformed from a management point of view. Much more needs to be done. It is interesting that Dr. Ambrose McLoughlin, who is named in the report, no longer works for the health service. He was a brave and committed administrator but he has left the health service.

There are issues around administration and management that need to be examined and the Government must become more proactive. My sympathies lie with the victims and I am disgusted that fellow doctors have been involved in such practices. Just as we rightly condemned individual members of the clergy in light of the Ferns Report so individuals who had a role in this must be exposed and condemned.

Photo of Liz McManusLiz McManus (Wicklow, Labour)
Link to this: Individually | In context

I commend the report and welcome members of Patient Focus to the Visitors Gallery. Judge Harding Clark has done an excellent job in meeting the requirements of a difficult brief. She has made some points about the practical problems she encountered in terms of lack of security and inadequate accommodation for her and her staff. Since investigations of this type are likely to recur, it would be wise to ensure these matters are addressed by the Government for the future. I welcome the role of this judge in formulating a compensation scheme for those who suffered so much and I will be vigilant in ensuring there is no undue delay in processing this scheme.

The terrible and tragic saga of the women who suffered at the hands of Dr. Michael Neary must lead to change in the health services. The first task, however, is to meet the needs of the women themselves. As one woman who had an unnecessary hysterectomy said:

I was so grateful eight years ago to be alive that any questions or doubts I may have had about my treatment went unanswered. I was given a second chance of life. I was unique. Dr. Neary had saved my life. The revelations over the past 18 months have shattered my illusions. I feel we have been living a lie all these years. What I believed and accepted as the truth was a lie. People have totally betrayed me and I now need, and feel I deserve, answers. How could this have gone unnoticed for so long in a hospital involving an entire body of people?

She has received answers to her questions in this report but she also posed a question of all of us. How can we ensure that something like this cannot happen again?

Last night the Labour Party put forward proposals for a whistleblowers Bill. We argued and will continue to argue that there is a pressing need for protection for whistleblowers, whether in the public or private sphere. If health staff working in Our Lady of Lourdes Hospital over the 24 years of Dr. Neary's practice had been protected in this way, the likelihood is he would have been stopped from injuring women much earlier than he was. It took an exceptional young midwife to stop him and the debt the women owe her, named as Ann in the report, is enormous.

Fidelma Geraghty, a woman who underwent an unnecessary hysterectomy after her baby was stillborn, said:

Everyone owes her a debt. If it were not for her, this could still be going on today and hundreds more women could have been affected. I would love to know who she is.

Judge Harding Clark states: "If it were in the power of the inquiry to make an award of bravery to any person, it would be to the midwife, whom we shall call Ann, who made the first complaint to the North Eastern Health Board solicitor".

The young midwife took a lonely, difficult route and until today she has maintained her anonymity, a fact that speaks volumes in itself. According to the report there was no forum for expressing her concerns, the implication being that there should be such a forum in every hospital and across the health services.

I was reminded recently that while Dr. Neary was practising at Our Lady of Lourdes Hospital, the health board was concentrating on suspending another consultant in the same area. This was in the early 1990s. Unlike Dr. Michael Neary, no disreputable practice was ever ascribed to Dr. Muldoon. His only crime was that, in the view of the health board, he kept his patients in hospital for too long. According to his colleagues his care of patients was exemplary but the health board was sufficiently exercised to suspend Dr. Muldoon.

Never, however, did it examine the terrible record of unnecessary procedures for which Dr. Neary was responsible. Even when Dr. Neary's work was examined by three fellow hospital consultants, they gave him a clean bill of health. Their recommendations chill the hearts of anyone reading them. One obstetrician goes so far as to state: "It is my view that the mothers of the North Eastern Health Board are fortunate in having the service of such an experienced and caring obstetrician". Later these consultants expressed regret and said that compassion and collegiality had affected their judgment. Their remorse is welcome but the lessons are crystal clear.

Change in how our health services are made accountable is imperative. There is a real danger that what is presented in this report will be seen only as having historical relevance but the report itself points out that there is still inadequate risk management in Our Lady of Lourdes Hospital, stating: "Interviews with professionals involved in clinical governance and risk management abroad lead me to believe that similar problems have occurred and do occur in other hospitals". If ever there was a warning for the future those words contain it. It is remarkable that there is no framework whereby hospitals are inspected, licensed or held to account.

We must take action on two fronts. I said in the Private Members' debate that a whistleblowers Bill had many applications but none more important than in our health services. Too often scandals have arisen because of a fundamental failure to ensure proper accountability and oversight. I instanced the hepatitis C scandal, the deaths of haemophiliacs, the nursing home charges and, most recently, the experience of patients of Dr. Michael Neary as testimony to that failure. The health services have no shortage of examples of systemic failure where it took actions by an individual to make a difference. The Labour Party offered an opportunity to legislate to protect the future midwife, bank official or public servant who sees a wrong and refuses to close their eyes to it. We can act by passing such legislation and should do so. That is the proper way to ensure accountability and it is long overdue.

One striking aspect of the report on Our Lady of Lourdes Hospital is the use on more than 20 occasions of the word "hierarchical" to describe the organisation of medical and nursing services. Judge Harding Clark writes:

Hospitals appear to run in a hierarchical system based on division of tasks. There is hierarchy among the nurses, and correlating medical hierarchy from the medical students to the interns, the SHOs, the registrars and the consultants.

She comments that hierarchy works well in normal life. There is much to recommend hierarchy where escalation of rank is based on degrees of competence and experience. A move up the ladder ought to be commensurate with experience and increased knowledge, with the higher echelons reserved for candidates who show leadership qualities. However, the report states: "If there is little upward movement or if promotion automatically follows tenure, hierarchical structures can create a negative and dangerous environment". There is no doubt that in the maternity unit of Our Lady of Lourdes Hospital, there was a dangerous environment. Largely due to the hierarchical approach and in deference to the judgment of superiors — not because information was unavailable or suppressed — basic questions went unasked and unanswered for many years.

We must encourage, not discourage, whistleblowing and divert protests into productive channels. I have made it clear that I do not believe it is sufficient to rely on the professionalism of doctors alone to police themselves. It is welcome that doctors increasingly work within teams rather than in isolation. However, the power relationship between consultants and junior staff, other medical professionals and patients is still imbalanced. The medical profession, through the Medical Council, has been pressing for reforms for up to ten years but its pleas have fallen on deaf ears. While allowing for reform of the Medical Council, it is important to recognise the role of whistleblowers. There will always be space for abuse no matter how good is the system of competence assurance.

A second important role is or should be that of an external inspectorate. We have inspectorates for schools, the Garda Síochána, psychiatric institutions, workplaces and prisons but we do not have an independent hospitals inspectorate. If it is to be truly independent, it should not be located in or under the Health Service Executive, rather in the Department of Health and Children or under a statutorily established health quality and information agency. Its remit should extend to State, voluntary and private hospitals and it should report to the Houses of the Oireachtas, reports that should be fully examined by Oireachtas committees.

On behalf of the Labour Party and as a result of what I have read in this report, I will publish this month our proposals for a hospitals inspectorate. What we have in mind is a chief inspector of hospitals and an appropriate number of assistant inspectors, including persons with relevant medical and nursing qualifications and other expertise, such as in administration. The inspectorate's functions would be to visit and carry out an annual review of hospitals and report in writing on the organisation and operations of those hospitals and the quality and effectiveness of services provided therein, including the quality of care and treatment of patients and hospital services generally, with comparisons with relevant international practice and standards. We should remember that it was someone from abroad who determined what was really going on upon examining the records of Dr. Neary's patients.

The inspectorate, as it considers appropriate, should report on the degree and extent of compliance by hospitals with any relevant enactment, directive, code of practice and such other matters relating to hospitals and the needs of hospital patients. The information collected should be disseminated and the inspector should have all powers that are necessary or expedient for the purpose of performing his or her functions. The chief inspector should have special powers to inquire into a report on the operation and administration of a hospital during a specified period or the care and treatment provided to a specified patient.

If change is to come about, it is vital that we establish a framework wherein hospitals and their work are examined thoroughly, openly and in a transparent way. This goes right across the board whether the issue is one of the maintenance or refurbishment of a hospital, recommendations for temporary or permanent closures, the numbers of patients — we clearly have problems with overcrowding — the staffing of a hospital, the introduction of reviews of specified policies, protocols and procedures and any other matter. Many issues, such as cleaning, maintenance, care and welfare of patients, design and even heating, lighting and ventilation, must be considered. In particular, the issues of records and data collection, which are the responsibility of hospitals, for how long they should be kept and how to make them safe should be considered. We all know that files were robbed from Our Lady of Lourdes Hospital, which is a criminal act. It is incredible that anyone could succeed in stealing such important medical material without somebody seeing what was going on or proper security being in place to ensure such a criminal act did not take place.

The experience of up to 250 women at the hands of Michael Neary has left a terrible legacy of sorrow and suffering. Individual women and men had their lives fundamentally altered and damaged by what one man did with impunity. Some people believed he was saving lives while others suspected what he was doing was deeply wrong but were afraid to act. One young woman called a halt and an administrator in the health board pursued the scandal into the open. Their courage is commendable, as is the dignity and determination of the women who lost so much at the hands of Michael Neary but stood and worked together to ensure that what happened to them will never happen to anybody else.

Our role must be to console and compensate, but it must also be to legislate to ensure that such a scandal does not recur in our health service. This means there is a requirement. It is not enough that the Tánaiste tells the House this or that must happen and everybody should behave better. We must have a plan of action in terms of the roll-out of legislation to deal with the issues raised in the Harding Clark report, which were not in the Tánaiste's report. A certain number of commitments have been given in respect of reform of the Medical Council but they do not go far enough. Beyond this, there have been aspirations but we now know that aspirations will not protect patients. There must be a statutory framework to ensure that patient care is fully protected.

This means we must do our jobs and legislate. Last night, the Labour Party moved a motion on a Bill for the protection of the whistleblower. I regret that the Government has shirked its duty and refused to take on board the Bill but we will persist. Protection of the whistleblower is our responsibility, as is reform of the Medical Council, and we will play our part when the Government publishes the documents. However, part of our responsibility must be to establish a full hospitals inspectorate to protect patients and, appropriately, pay tribute to the pain and suffering caused in one of our hospitals to so many innocent women who deserved the very best but did not receive it or get our protection.

Photo of Séamus KirkSéamus Kirk (Louth, Fianna Fail)
Link to this: Individually | In context

Deputy Connolly is a member of a group of speakers.

Paudge Connolly (Cavan-Monaghan, Independent)
Link to this: Individually | In context

I propose to share time with Deputies Gormley and Ó Caoláin.

Photo of Séamus KirkSéamus Kirk (Louth, Fianna Fail)
Link to this: Individually | In context

Is it an equal sharing of time?

Paudge Connolly (Cavan-Monaghan, Independent)
Link to this: Individually | In context

Yes.

Photo of Séamus KirkSéamus Kirk (Louth, Fianna Fail)
Link to this: Individually | In context

I will remind the Deputy when his time has concluded.

1:00 pm

Paudge Connolly (Cavan-Monaghan, Independent)
Link to this: Individually | In context

I welcome this opportunity to speak on the Our Lady of Lourdes Hospital inquiry and report into the events that transpired therein. I commend the report which is readable and a good job was done. I pay tribute to the Patient Focus group, which can only be described as excellent — its members are in the Visitors Gallery. Its persistence is beginning to be rewarded. I was concerned when the Tánaiste stated she would need cross-party support but I hope the Government will take on board the suggestions of this report. The report makes for sad reading, revealing that barbaric practices continued for so long with no one shouting "stop". The report focuses on hysterectomies performed by Mr. Neary. It does not refer to the death of babies, the removal of ovaries and Fallopian tubes, the disfiguring of women as a result of operations, or the lives destroyed because of physiognomies as these issues were outside the scope of the inquiry. The report does not refer to the baby who lived for two days and whose birth and death records are not available. Many issues are not addressed by this report.

However, Judge Maureen Harding Clark did a good job in producing a report of such quality. The report is part of the process and the speed at which events take place is what will determine the value of the report. This will not be known for some months.

The report highlights a number of issues that give rise to grave concerns about professionals investigating their peers, as has been referred to by earlier speakers. Three obstetrician gynaecologists were asked to investigate events in the maternity unit of Our Lady of Lourdes Hospital in Drogheda. This was an investigation into malpractice rather than a regular inspection and one would have expected it to be taken seriously. Despite being forewarned, these three gynaecologists found nothing wrong. They effectively endorsed practices at the maternity unit in the hospital. Subsequently, Mr. Neary was in a stronger position as he had been endorsed by his peers, the strongest endorsement one could receive. How could three professionals not see the barbaric practices, which were 20 times above national and international norms? Did they not wish to see the practices that were taking place or did they close professional ranks? The latter should not be ruled out.

The fitness of these three individuals to carry out an investigation is flawed and because endorsing malpractice is the ultimate wrongdoing in an investigation. Three statutory bodies should also engage in self-examination. The Royal College of Obstetrics and Gynaecologists has made a number of reports on the hospital. The Royal College of Surgeons approved the unit for undergraduate training and An Bord Altranais inspected the hospital to ensure it was a suitable place to train midwives. The public is reassured when eminent bodies such as these undertake inspections as they provide a degree of quality assurance. Such bodies are acting on behalf of the public and often the Government acts on foot of reports received by such bodies. The experience of hospitals in Monaghan shows the negative aspect of what the Royal College of Surgeons has done and we know the tragic consequences that resulted. What credibility do such bodies hold after what happened in Drogheda?

The issue of compensation must be urgently dealt with to bring closure to this case. The case of Alison Gough, contested in the High Court provides a benchmark in these circumstances. The High Court reduced the amount of money awarded and the Supreme Court has now ruled on the matter. These are the same victims, with the same injuries caused by the same malpractice. I urge the Government to acknowledge the benchmark and do the decent thing rather than putting women from Patient Focus through the court system again and throwing more money to the legal system. This should be dealt with as a matter of urgency. These women should be allowed to unburden themselves as part of the healing process.

Other cases exist at Our Lady of Lourdes Hospital, including those referred to as cases of bad outcome. A number of these cases occurred between 1974 and 1998 and must be examined.

The report's 156 recommendations should be urgently examined. I will return to this matter to review the number of recommendations implemented. The Garda Síochána now has a report, which we are awaiting, and I hope this will prevent something similar happening in other hospitals.

Photo of John GormleyJohn Gormley (Dublin South East, Green Party)
Link to this: Individually | In context

I wish to share time with Deputy Ó Caoláin. I welcome the women of Patient Focus to the Dáil and congratulate them on their courage and tenacity in pursuing this issue. They sought only truth and justice but their struggle is not yet over. We will have no closure, truth or justice until all the women who suffered can tell their story and be properly compensated.

I welcome the fine report from Judge Maureen Harding Clark and the clarity of its presentation, for which I thank her. The Tánaiste is familiar with the Department of Finance and is aware this Department controls the purse strings. I do not wish it to engage in insensitive penny pinching and I want the Tánaiste to bang the table and represent these women to ensure they are adequately compensated.

Although we refer to the victims of Mr. Neary and 129 Caesarean hysterectomies, what about the 42 victims of Dr. Lynch? All these people must be heard. It is incredible that three obstetricians could have examined this in detail and given Mr. Neary and others in the institution a clean bill of health.

The Tánaiste will be familiar with some of the stories not included in the report that have emerged. Stories of women who went in for minor treatment and had their ovaries removed are horrific. Such women have struggled with early onset of the menopause, health difficulties and suppression of their immune system. I will not belabour the point addressed by the previous speaker. These problems are due to the gross arrogance of certain people in the hospital. We cannot forget these victims. The Tánaiste's speech compared the victims' stories to a Gothic novel and I would compare it to a David Cronenberg film.

Let us discuss compensation. The Alison Gough case, in which compensation of €250,000 was reduced to €200,000 in the Supreme Court, remains the benchmark. Both the Government and Opposition believe this should be investigated. These events happened because of extreme arrogance and the abuse of power. It was a closed shop wherein the consultants were the dictators and instilled awe and fear. Like other speakers I salute the courage of the midwife who blew the whistle. These events are evidence that legislation to protect whistleblowers is required to protect those few people who have the courage to come out. The report states that this is a story set in a time of unquestioning submission to authority, whether religious or civil, when nurses and doctors were in abundant supply and permanent jobs were few and treasured. This is the pressure under which they worked.

The report examined the rate of Caesarean hysterectomy in other hospitals. The rate was one per 600 sections in the Coombe Women's Hospital, one per 405 sections in Holles Street, one per 42 sections in Drogheda and Mr. Neary's rate was one in 20 sections. This should have been sufficient to set off alarm bells.

I refer the Tánaiste to today's Irish Independent and ask her to listen because it is important. An article written by a constituent of mine, referred to recent statistics issued by the Irish maternity units. It states that the statistics for accelerated labour rates in first-time mothers are 14.7% in Letterkenny and 55% in the National Maternity Hospital, Holles Street. The epidural rate is 12% in the Midlands Regional Hospital and 80% in Ballinasloe. The episiotomy rate is 46% in Tralee General Hospital and 7.8% in St. Finbarr's Hospital in Cork. These figures show the significant diversity which the writer maintains can only reflect the personal preferences of the obstetricians. They continue to call the shots.

Before other tragedies and difficulties occur I ask the Tánaiste to examine the way different hospitals operate. She should study those statistics and consider the reason that people can dictate in such a way and whether people are now keeping quiet, because there will be more difficulties if they are. It does not end here and solutions must be found. The Tánaiste is making some progress but many people are still in awe of these consultants.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
Link to this: Individually | In context

In addressing the Harding Clark report tribute must be paid first and foremost to the courageous women who with Patient Focus have struggled for justice over many years. To them alone must go the credit for revealing the full horror of what went on in Our Lady of Lourdes Hospital in Drogheda. To these women also we owe a debt of gratitude for highlighting many fundamental flaws in our hospital services which are exposed in this report and from which lessons can and must be learned and implemented.

Ar an lá seo, Lá Idirnáisiúnta na mBan, gabhaimid buíochas leis na mná seo a rinne seirbhís, ní dóibh fhéin amháin ach do mná na tíre agus don bpobal ar fad.

It is vital that the Government moves swiftly now to implement the recommendations of the report and establishes the redress scheme for all the women victims of malpractice in Our Lady of Lourdes Hospital. The Tánaiste and Minister for Health and Children has stated that the redress scheme does not require legislation and that necessary legislation with regard to the pursuit of insurers can proceed in parallel and this is to be welcomed. We await clarity on the timescale as experience with other redress schemes has not been good. In the case of Our Lady of Lourdes Hospital many of the women have been waiting decades for justice. No further delay should be countenanced and everything should be up and running before the summer.

Last evening the members of the Oireachtas support group met the representatives of Patient Focus. We reiterated our call, issued before the publication of the Harding Clark report, for the immediate establishment of a redress board. It has been emphasised to us by Patient Focus and we have made clear in a letter to the Tánaiste this morning the need for all of the women concerned to be included under the terms of the redress scheme.

The victims of Mr. Neary and others who practised in the maternity unit at Our Lady of Lourdes Hospital require and deserve a redress scheme that fully accommodates their need to have their experiences outlined and heard. All victims of Mr. Neary and others should be accommodated. The scheme should not be confined to the 129 cases of Caesarean hysterectomies performed by Mr. Neary but should include all those and without exception, who were subjected to this brutal procedure, some 59 further cases. It should also encompass all other bad outcomes, including those who had their ovaries removed and the cases of the babies who died. It is not anticipated that the number of cases involved would exceed 250. These are the priorities so far as the women victims themselves are concerned.

The report raises many other fundamental issues about the operation of our hospital services and its recommendations are wide ranging, with implications far beyond the confines of one hospital in Drogheda. The biggest question it raises is how such gross malpractice could have been allowed to continue for 24 years with no one shouting "stop". It should not be forgotten that but for the decision of two midwives to raise concerns in 1998 the full truth might never have been told. Why was this the case? The report highlights a system characterised by authoritarianism, elitism, lack of accountability, lack of consultation, inadequate training and bad management. Judge Harding Clark states that the story is "set in a time of unquestioning submission to authority, whether religious or civil".

It is clear that Mr. Neary operated without being accountable to anyone. A strict hierarchy existed in which all staff were expected to know their place. I was reminded of a statement of a former Minister for Health and Children, Deputy Martin, when he said that hospital consultants were, "kings in their own domain". This was certainly the case of the consultants who worked in the maternity unit at Our Lady of Lourdes Hospital.

This is not ancient history. The first so-called inquiry into this scandal was carried out by professional colleagues of Mr. Neary. They examined the cases of nine women, cases carefully selected by Mr. Neary himself. This sham exonerated Mr. Neary. Judge Harding Clark is being very generous when she says that those involved in this sham inquiry reached their conclusions on the basis of "compassion and collegiality". If it was compassion, it was not compassion for the women victims of their colleague. If it was collegiality, it was a misplaced loyalty within a profession that too often has protected itself and placed the interests of its members as a body and as individuals above the interests of patients.

The Medical Council also has much to answer for. Why did it take the Medical Council from June 2000 to July 2003 to complete its investigation? While this investigation finally led to the striking off the register of Mr. Neary, its long duration was a cause of much distress to the women concerned. With much wider scope and more detailed terms of reference, Judge Harding Clark took far less time to complete her report.

The scandal is that all of this took place in a hospital funded by the Government to treat public patients, yet the State provided no proper system of oversight and accountability for those into whose care it had placed our citizens. I reiterate my concern about the hospital consultants' common contract. The existing contract reflects the era of lack of accountability and elitism in which the Our Lady of Lourdes Hospital scandal was allowed to continue. The report states that to this day consultants are spending too much time with private patients yet the renegotiation of the contract is long overdue and there seems to be little progress in this regard.

The Tánaiste stated last week that the report confirms the appropriateness of the actions being taken by the Government across a range of health issues. This remains to be seen, given the Government's record so far. This report should be a clarion call that contradicts another statement by the Tánaiste shortly after her appointment to the Department of Health and Children in December 2004, as follows: "I believe in a minimalist role for the State in all our lives, including health care". In the Our Lady of Lourdes Hospital scandal the problem was that the State had not only a minimalist role, it had abandoned its responsibilities. If the women are to get justice, their call in all its dimensions must be heeded and acted upon and the State must face up to its responsibilities not from a minimalist disposition, but to be the guardians of the interests of all patients in its jurisdiction.

Jim Glennon (Dublin North, Fianna Fail)
Link to this: Individually | In context

I join my colleagues in complimenting Judge Harding Clark on her excellent report and the manner in which she conducted her inquiry. I also compliment the brave midwife who stood up and shouted "stop". I welcome members of Patient Focus to the House and particularly compliment and congratulate them on their resilience, persistence and, above all, dignity in the face of significant personal adversity. I do not intend to go into detail on the report but to briefly examine the culture that brought us here today.

We know the midwife shouted "stop", but we must examine who knew but did not shout "stop": the obstetricians who worked in the unit and who knew of the operations; the junior doctors and the post-membership registrars; the anaesthetists who received the patients, administered the anaesthesia, wrote the operation notes, spoke to each patient in the recovery room and were always present during the operations; the surgical nurses, frequently midwives, who handed the hysterectomy clamps to the surgeons and counted the swabs; the midwives who cared for the women after their operations and who recorded each day, with the honourable exception of the lady who called "stop"; the pathologists and technicians who received the wombs and specimens from the maternity theatre to be analysed; and the Medical Missionaries of Mary, who owned the hospital for most of the period involved.

There are also some people whose silence I find particularly difficult to understand. Not one of the vast range of GPs for the women, each of whom treated the individual patients and was detached from the circle of immediate influence in the hospital environment, raised a question. None of the parties who read the maternity hospital's annual reports shouted "stop". As for the visits to Drogheda from the "gentlemen" of the royal college, where they had lunch with Dr. Neary in his home and dealt with files selected by Dr. Neary, I wonder what they thought they were doing. Were they acting in their professional capacity or were they there for a day out? I wonder if they took in a round of golf at Baltray. Reading the report it appears that these so-called inspections took place in such an atmosphere. The word "royal" raises questions. Why do we not have our own Irish institute? We do not have to do our own inspections but could get inspectors from outside. A "royal" institute having an input in this country is an anachronism.

The anaesthetists described Dr. Neary as a "safe pair of hands". They thought Dr. Lynch was professional and competent, a quick and clean worker. They thought Dr. Neary might have been a little hasty to resort to hysterectomy. One suggested to the inquiry that obstetricians had gone the other way and were too slow to resort to hysterectomy. Incredibly they were unaware of comparative statistics. Pathologists seemed to know the number of hysterectomies but did not know of any benchmark figure to use as a comparator and had no concerns regarding surgeons. The newest pathologist was concerned about the number of uteri and ovaries he saw in the laboratory. In the final nine months he had resolved to discuss the matter with Dr. Neary but, unsurprisingly, that never took place. These are the fellow consultants of Dr. Neary. One would not expect they could be easily cowed or intimidated. They are of equal rank in the medical hierarchy: anaesthetists, pathologists, obstetricians and gynaecologists.

One aspect of the report staggered me. The medical board, again made up of consultants, was unaware of what went on in the maternity units. That begs the question what is the function of the medical board of any hospital if it is not to oversee the medical work there. Here we have a board made up of consultants unaware of what went on in the units. I have dealt with the outside obstetricians briefly. It is interesting that nobody to whom any of the annual reports were sent raised queries. Dr. Neary informed the inquiry that no queries were ever put to him arising from the annual report. Amazingly the reports in the 1970s through to 1984 were published openly, including the number of Caesareans and hysterectomies. It was confirmed to the inquiry by the royal college in London that these reports were archived and not read. What is the point in furnishing the reports to an outside body if they are just to be filed? They could be filed in the hospital, although they could then be easily removed, as many of the files were. Maybe they could be filed in the Drogheda library for all the good the forwarding to London provided.

On justice for these dignified ladies, I agree with my colleagues who suggest that the Alison Gough case should be the benchmark for compensation and that the same criteria used in that case should be applied in all other cases. I suggest that the role of the MDU not only in Drogheda but in the Irish medical system generally should be examined. It is anachronistic that discretionary cover is provided for all our consultants and the majority of GPs and that no contract of insurance is required for registration with the Medical Council. A hearing is an essential and integral part of the process for the ladies.

It is ironic on International Women's Day that I suggest the role of the husbands and partners, who have also suffered to a significant degree, should be recognised in whatever process is agreed. The Medical Council should immediately reopen an investigation into the 59 cases other than Dr. Neary's, mainly Dr. Lynch's. I recently listened to the chairman of the Medical Council, a man for whom I have high regard, discuss its forthcoming reform. He mentioned that there should be more lay involvement in the Medical Council, with which we all agree, but set the limit at 12. The Medical Council consists of 25 members. Why should there not be a majority of lay people on the Medical Council? Why should the profession which is being policed by the council, as it were, retain a majority on it? I do not know. I am asking the question. I will be interested in the debate on the Medical Council and I look forward to it.

The Director of Public Prosecutions should review all the files again and I understand that moves are afoot in this regard. We have heard much of the phrase "meaningful audit in the future". The important word is "meaningful". As for the storage of records some back-up system must be introduced to obviate the ridiculous situation of missing records. We cannot have the scenario, which is now in prospect, where each patient seeks his or her records on leaving a doctor's surgery. Unless we come up with an appropriate system, that could well be the situation.

I again compliment and congratulate the midwife who shouted "Stop". I congratulate Patient Focus and wish it well for the future. I also compliment the Tánaiste on the sensitive manner in which she has dealt with this matter so far. We look forward to that continuing into the future.

Sitting suspended at 1.35 p.m. and resumed at 2.30 p.m.