Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I thank the Ceann Comhairle for allowing me and Deputy Ó Caoláin to raise this important issue.

The outbreak of C. difficile at Our Lady of Lourdes Hospital in Drogheda did not come as any surprise to many of the patients and families attending that hospital. While we all appreciate the extraordinary workload that has been forced on the hospital in recent years, there were constant complaints to me - and, I am sure, to many others - about the problem of overcrowding and lack of cleanliness.

Clearly, what has happened in the north east has been the result of total mismanagement of resources. A total of €17 million was spent on the Monaghan General Hospital restructuring programme and the only way it should have been wound down was with the building of a new central hospital in Ardee. In fact, the Teamwork report, bad as it was, made it clear that only when proper structures were in place should the existing structures be removed. It is totally unacceptable for a patient to go in with a fractured bone and come out dead a short time later.

This is not a problem only at Our Lady of Lourdes Hospital; there is serious overcrowding at Cavan General Hospital as well. In the old days the matrons got their priorities right and made sure administration was at a minimum and that front line staff, nurses, trainee nurses and attendants were all in place and doing their job. I was recently told by the father of a young girl about their experience in Cavan General Hospital. She arrived at 11.45 a.m. in dreadful agony with suspected appendicitis, but she was eventually seen at approximately 6 p.m. The waiting area was full of trolleys. The girl's father was told she would be kept in that night and operated on first thing the next morning. However, the operation did not take place until 7 o'clock the following evening and she was sent home at 11 a.m. the following day. This is a personal story, just one of many of which I have been advised regarding both acute hospitals. Having said that, those who get through the system have nothing but praise for the attention and care they received.

When swine flu was deemed an epidemic I urged both Professor Drumm and the Minister for Health and Children, Deputy Harney, to ensure that the 55 beds in Monaghan were left in place as a backup, at least for the time being, but of course this was ignored. Tonight I would like to receive some indication from the Minister about whether there are any plans to ensure people can get to hospital if required without having to leave the area, which would minimise family access.

I said in the House on a previous occasion that the way the health service was being run by the Minister was in fact euthanasia by the back door. I hoped at that stage that a warning would be sufficient, but unfortunately it was not heeded.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join with Deputy Crawford in appealing to the Minister of State to reflect our concerns to the Minister, Deputy Mary Harney, whose absence I regret given the seriousness of the issue.

We know of the report to the Louth county coroner on the deaths of four patients in the outbreak of C. difficile at Our Lady of Lourdes Hospital, Drogheda. The HSE reported that there have been approximately 21 confirmed cases and 20 symptomatic cases at the hospital. We also know there has been a further outbreak at Our Lady's Hospital in Navan and that these outbreaks have resulted in the closure of a significant number of beds at both hospitals and the cancellation of surgical procedures and all physiotherapy appointments at Navan hospital. Visiting restrictions have been put in place and all elective orthopaedic procedures and some general surgery has been cancelled until further notice at the Navan hospital site. These are serious consequences in the north-east region, where one hospital has already been closed for all acute care since 22 July. We now have two critical hospital sites, in Drogheda and Navan, working under a strict and limited regime. The closure of acute services at the Louth Hospital in Dundalk has been signalled as and from the end of the coming month. This is a very serious situation that requires an emergency response. We argue that here we have a hospital site that does not have the infection currently present in Monaghan hospital and it deserves to be considered for the restoration of acute care as an emergency response to the current situation. We ask the Minister to recognise that while Monaghan hospital offers a temporary reprieve from the current difficulties we believe the closure of the hospital site is a direct contributor to the difficulties at other hospital sites within the region. Already hard-pressed staff and the extended throughput of patients presenting at each of these hospital sites both contribute directly to a fall in the standard of hygiene care and the ability of staff to enforce mandatory handwashing and the use of the gel opportunities provided at all the ward sites.

I appeal to the Minister to respond to a situation that is currently localised in the north eastern region which requires a similar north eastern response.

John Moloney (Laois-Offaly, Fianna Fail)
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I apologise that the Minister, Deputy Harney, cannot be present. I shall depart from my prepared script for a moment. I absolutely resent the scurrilous allegation by Deputy Crawford. I do not believe he knows the meaning of the word "euthanasia". If he did he would not have said what he did.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I know exactly what I said.

John Moloney (Laois-Offaly, Fianna Fail)
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If the Deputy took some time to read recent reports on the success of the health service he would realise the age profile of people in this country has far outgrown that of many of our European colleagues. For the record, the Minister, Deputy Harney, with whom I have had the honour of working during the past year, is honest, decent and courageous. I could think of many more adjectives to describe her hard work and, most important, her caring position as Minister for Health and Children. However, I do not expect the Deputy to apologise. That would be far too much to ask.

At the outset, I wish to express my apologies to the patients and their families who have been affected by the outbreak of clostridium difficile. I share the Deputies' concerns in relation to C. difficile and healthcare associated infections,HCAIs, generally. Since the beginning of October, there have been 22 confirmed cases of C. difficile at the hospital. There are currently ten confirmed cases. All confirmed cases were initiated on appropriate treatment for C. difficile and the majority of patients have responded to these treatments. In the same period a further 30 patients were symptomatic. Most of these patients have since improved. However, 11 patients remain symptomatic. There are currently 99 beds closed at Our Lady of Lourdes Hospital, Drogheda.

C. difficile is a well recognised HCAI. National guidelines for the surveillance, management and control of C. diff icile-associated disease are implemented on an ongoing basis in Our Lady of Lourdes Hospital in order to minimise the impact of an outbreak on all patients, staff and the general public. They include guidance on the prescribing of certain antibiotics to prevent infection, case finding, risk assessment of symptomatic patients, isolation of patients who pose a potential or actual high risk of infection to others, mandatory hand hygiene and other infection control measures.

The C. difficile outbreak in Our Lady of Lourdes Hospital was reported on 28 October. I have been assured by the HSE that all appropriate infection control procedures and practices have been put in place. These include the following: an outbreak committee has been convened in accordance with the national guidelines; a renewed emphasis on medication prescribing with increased restrictions on the use of certain antibiotics, laxatives and other drugs in line with expert advice available to the committee; three wards in the hospital were identified and used to implement stringent isolation and control measures; there has been targeted emphasis on mandatory hand hygiene and other infection control measures; ongoing education of all grades and disciplines of staff to update on the status of the outbreak and measures that staff can take to care for the patients affected and minimise the further spread to unaffected patients and contain the outbreak.

The outbreak committee has sourced specialists to assist with deep cleaning of affected wards and hospital equipment. Specialist engineers have been drafted in to decontaminate most of the affected areas of the hospital and these measures will continue on an ongoing basis.

C. difficile is a notifiable disease which means that a doctor is legally bound to notify the coroner in all cases where a person has died who may have been exposed to or contracted a C. difficile infection. The coroner is responsible for determining if C. difficile was the cause of and-or contributory factor to a person's death.

Since 6 November, in consultation with the Louth county coroner, the HSE's clinical director has agreed that all deaths occurring at the hospital during the escalation phase of the outbreak will be notified to the coroner as a matter of routine. Prior to 6 November two deaths involving C. difficile as a suspected contributory factor were notified to the coroner and since 6 November, there have been a further four deaths at the hospital which have all been notified to the coroner. The HSE expects that a number of these cases will not be attributable to C.difficile. The families of the deceased have been contacted and have been offered appointments to meet with the treating clinician.

Restrictions remain in place at the hospital and general practitioners and ambulance services have been requested to refer adult patients, with medical complaints to other appropriate hospitals. Members of the public are asked to attend the emergency departments at the hospital only in the case of a genuine emergency and to contact their GP or out-of-hours service in the first instance. Visiting restrictions remain in place and where visitors are permitted they are being advised of the need for appropriate hygiene protocols including thorough hand washing.

For the moment all elective medical and surgical procedures have been cancelled. Measures have been put in place to deal with all priority 1 endoscopy procedures, namely, urgent endoscopes for diagnostic or therapeutic purposes. Arrangements have now been put in place to provide an orthopaedic and hip fractures service within the three North Dublin hospitals as a result of a C. difficile outbreak which was called in Navan on 13 November. There are two confirmed cases of C. difficile at Our Lady's Hospital Navan.

Surgical services continue to be provided across the Louth Meath Hospital Group. Elective day case surgery continues to be provided in Our Lady's Hospital and Navan and Louth County Hospitals and is being managed on the basis of individual patient needs. Contingency arrangements are in place in Beaumont Hospital for level 2 and level 3 surgery, for example, acute surgical or urgent elective. Through proactive management of clinically discharged patients at both hospital sites, capacity has been developed to deal with the requirement for patients in Louth County Hospital. As the outbreak continues all of the above are being reviewed on a daily basis and all appropriate measures will be taken to ensure timely access to quality safe services in line with patient need.

The World Health Organisation declared a global flu pandemic in June 2009. Since then my Department and the HSE have implemented plans to deal with the pandemic in Ireland. HSE national and crisis management teams are meeting regularly to co-ordinate HSE preparedness and response to issues such as the pressures being placed on the acute hospital system during the pandemic. A mass vaccination programme is underway through general practitioners and through public mass vaccination clinics which have been established all over the country.

I am satisfied that both the C. difficile and swine flu issues are being managed appropriately.