Denis Naughten (Roscommon-South Leitrim, Independent)
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I thank the Leas-Cheann Comhairle for giving me the opportunity to raise this important issue. I acknowledge the presence of the Minister for Health. I welcome the establishment of an independent investigation into the issues surrounding the care of seven babies at Portiuncula Hospital in Ballinasloe.

The least the parents deserve is to know the truth about what happened in the cases of each of the seven children. I reassure expectant mothers that Portiuncula Hospital has been audited on a number of occasions since the initial review began and has come through each one. Expectant mothers have nothing about which to be concerned with regard to their care in the hospital.

I wish to raise a specific issue of concern which needs to be included in this investigation. This is the fact that HSE management was made aware of the staffing, supervision and training concerns by staff and midwifery management as far back as July 2013. Midwives in Portiuncula Hospital have consistently highlighted the lack of inadequate staffing at the maternity unit. Instead of having one midwife to 28 births, last year Portiuncula Hospital operated on a ratio of one midwife to 54 births, which is almost half the number of midwives required.

In July 2013 the staffing situation was so serious the matter was brought directly to the attention of the group chief executive officer, Bill Maher, the group chief operating officer, Tony Canavan, and the group clinical director, Dr. Pat Nash. The correspondence informed all three that funding was needed to appoint midwifery trainers in all of the maternity hospitals in the group. The communication circulated to the three most senior managers of the hospital group stated these appointments were important to ensure recommendations and learning from recent reports were applied. This took place less than one month after the HSE report into the tragic death of Savita Halappanavar found the key factor in her death was inadequate assessment and monitoring. It was well before the spike in the number of babies transferred from Portiuncula Hospital to Dublin for therapeutic cooling in 2014.

Michael Fitzmaurice (Roscommon-South Leitrim, Independent)
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I sympathise with all of the families who have suffered in this. I reiterate Deputy Naughten's comments that Portiuncula Hospital in Ballinasloe is a good hospital. Let expectant parents not be afraid. However, we need a proper and transparent investigation which is not biased in any way and the end game of which is not to try to close the hospital. We have seen enough of this through the years. We want to learn from mistakes. I urge the Minister to let this be completely independent. Do not involve in any way the people who have brought out reports. Do not use the people who want to do hatchet jobs on hospitals, particularly those in the west. Let those involved be open and transparent.

It is a sad day when media outlets, such as thejournal.ie, are those who inform parents, and someone from the health services cannot pick up a phone, drive to a house or write a letter to inform them. Will the Minister ensure this is done right? We should learn from mistakes. Staffing is a major problem, as Deputy Naughten stated. My children were born in the hospital in Ballinasloe and I cannot but give it the utmost praise. No Deputy wants what usually comes out of these investigations, which is a finding that a hospital may not be safe after which an attempt is made to close it. Portiuncula Hospital is needed for Roscommon and east Galway. It has had a credible reputation throughout the years so let us get it right.

Leo Varadkar (Dublin West, Fine Gael)
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I thank Deputies for raising the issue and affording me once again the opportunity to extend my sympathies to the families involved. I know this is a very difficult time for them, but I have been advised that the HSE is in contact with them and they will be offered the necessary supports.

While I am of course very concerned to learn of the events in Portiuncula Hospital, I take some reassurance from the fact that a quality and risk management process highlighted a potential problem and the Saolta University Health Care Group acted promptly to review the situation. Protective measures were very swiftly implemented to provide patient safety assurance and an intensive ongoing monitoring process has been put in place.

An external review of practices and processes will now be commissioned to ensure the ongoing safety of maternity services at Portiuncula Hospital. The review will incorporate a more detailed review of the individual cases.

I have no desire to add to the concerns of any woman who may be expecting a baby and I urge others not to do so. I thank the Deputies for their helpful comments in this respect. I believe it is very important to reassure women, and their families, that maternal and perinatal health statistics indicate that Ireland continues to be a safe country for a woman to give birth in, and our safety record compares favourably with other developed countries. The European health consumer index published this morning, which was critical of some aspects of our health service, pointed out that when it comes to perinatal deaths Ireland is in the best and safest group. I share the view of Deputies that we must seek to improve the services we provide, and in this regard a number of initiatives have recently been implemented or are being developed.

The Department, in conjunction with the HSE, is working on the development of a new maternity strategy. Developing the strategy will help us identify how we can improve the quality and safety of care provided to pregnant women and their babies. We want to ensure that women are provided with the right care, in the right setting, by the right staff, at the right time.

I note the launch last November of the Irish maternity early warning system, IMEWS. This national clinical guideline will assist in the early identification of deterioration and ongoing monitoring of a woman's condition. This development makes Ireland one of the first countries in the world to introduce a national maternity early warning system.

A sum of €2 million in additional funding has been provided in the national service plan for 2015 to address current pressures in maternity services through the recruitment of additional obstetricians, midwives and other front-line staff. In this context it is important to note that while of course we would like to have even more staff, we have more consultant obstetricians and substantially more midwives than ever before at a time when birthrates are decreasing. A new national maternity office will be established within the HSE acute hospitals division in 2015, and a national review and evaluation of maternity services will be undertaken.

I reassure women and their families that Ireland is and remains a safe place in which to give birth. While perinatal and maternal deaths in Ireland are few, I know this is of no consolation to those families who have suffered a loss. I assure them that we will seek to continue to increase the safety and quality of services provided to mothers and their babies in our national maternity service.

Denis Naughten (Roscommon-South Leitrim, Independent)
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I am disappointed with the response that it will be purely focused on Portiuncula Hospital. I understand the management of the Saolta University Health Care Group was made aware by the hospital itself of the transfer of the babies from Portiuncula Hospital for therapeutic cooling after the first two babies were transferred and after the second two babies were transferred. Why did it fail to act on the concerns expressed by staff? We need clarity on the management of the care of each baby, which the parents deserve. They also deserve to know why they were not informed of the inquiry until they were told by the media. We also need to know why the resource concerns raised by the midwives in the hospital, and by local and group management, seem to have been ignored. This is the key question. If those concerns were addressed would there be a need for this inquiry? This needs to be answered.

It was the staff in Portiuncula Hospital who raised this issue. They are the people who pushed for a review to take place. Therefore they should not be scapegoated. We need a proper independent inquiry which not only examines what happened in Portiuncula Hospital but why senior management failed to act when these issues were brought to their attention.

Michael Fitzmaurice (Roscommon-South Leitrim, Independent)
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Everything will be done to resolve this and an independent inquiry will take place, but the one thing the people, particularly those in Ballinasloe and its surrounding area, need to hear the Minister state is the hospital will continue to deliver babies. A sad reality in Ireland in recent years, before the Minister took over, was that when a hospital cried for help because of staff shortages and being under pressure the type of thinking in senior management in the HSE has been to try to close it. This must change.

The front-line staff in the accident and emergency department in Portiuncula Hospital were under horrendous pressure last Christmas. That must be addressed. People, regardless of where they live in Ireland, deserve a health service. As well as ensuring that the inquiry will be independent, I urge the Minister to confirm that this hospital will continue to provide services and that its staff need not be wary or wondering about its continued operation. The wondering that is prevalent about it at present is not helpful in the situation.

Leo Varadkar (Dublin West, Fine Gael)
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To the best of my knowledge the terms of reference have not been yet decided. I welcome the Deputy's suggestions as to what might be in them. The inquiry will be independent and will be led by people who are outside the Saolta hospital group and it will also include a patients' advocate.

The reason some of the families were informed through the media was due to the fact that it was leaked to the media. I do not know who was responsible for that leak but it is very regrettable because the hospital and the other authorities should have been given time to contact the families, but sometimes things are just too good a story for them to avoid publication. I know that at least one media outlet decided not to break the story in deference to the families' wishes but, unfortunately, others did not take that approach.

In regard to the therapeutic cooling, it is important to bear in mind that while the rate of therapeutic cooling was higher in Portiuncula than in Galway, it was not outside the international range of norms and it was not that in itself that created concerns. It was the subsequent review of the cases that threw up concerns.

On staff ratios, I do not know offhand what the midwife to birth ratios are in Portiuncula or whether they are very different from other hospitals or larger hospitals. However, one aspect needs to be pointed out. In medicine and in midwifery the more cases one sees, the better, and then one is more used to seeing a difficult case when it arises. If a centre, and I not speaking particularly about Portiuncula, has 1,500 or 2,000 births, which is probably five or six a day or two or three in each shift, one is less likely to know what to do when that one in 700 cases arises. Sometimes having more staff does not necessarily make services better. What we need are senior staff and we have a difficulty getting and retaining senior staff, particularly at registrar and senior house officer, SHO, level, in smaller centres. That is a reality we face across the country. We need to be honest with people about that and the difficulties that can arise from that. When one looks at inquest reports from maternal deaths and neonatal deaths, the deciding factor is not that the staff were too busy to do their jobs, it is that they made a mistake in reading a cardiotocography, CTG, or detecting a foetal heartbeat or something else. That can often be down to lack of experience and lack of case volume rather than there not being enough staff. Certainly, what I can say, and I will be straight about this, is that there are no plans to discontinue maternity services in Portiuncula. That is not part of this Government's agenda.