Seán Fleming (Laois-Offaly, Fianna Fail)
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I am pleased to have the opportunity to speak on a very sad and difficult issue for everybody involved at the Midlands Regional Hospital, Portlaoise. We must primarily hold in our thoughts the five infants who are no longer with us as a result of incidents in the maternity unit in Portlaoise, and the devastation it has caused to their families. I thank the families for their courage in pursuing the matter and RTE for having highlighted in on "Prime Time". If the families had not been so strong and brave, we would not be here having this debate and HIQA would not have produced its report. While there were faults at local and regional level, the major faults were at the level of senior management, which presided over unacceptable risks for patients. Senior management in the HSE knew about it over years and the State Claims Agency notified them about various incidents in Portlaoise hospital.

6 o’clock

The bottom line is that the HSE senior management was aware of the problem. Not only did it do nothing about it, it actively covered it up. We saw the row over the publication of the report. I am sure some in the HSE sought to prevent it coming out.

None of that takes from the difficulties at Portlaoise hospital. Will the Minister ensure the recommendations are implemented in full and confidence is restored in the interests of patients and those who want to use the hospital in the future? This afternoon the Taoiseach made an extraordinary comment when he said there are accountability and disciplinary action procedures for doctors and nurses but not for senior management. That is where the Minister must ensure there is accountability with senior management in the HSE. Otherwise, he cannot stand over the HSE when he comes into this Chamber. HIQA says it cannot stand over Portlaoise hospital. Accordingly, the Minister cannot stand over the HSE unless he can be sure he has accountability in the service.

Billy Kelleher (Cork North Central, Fianna Fail)
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I concur with Deputy Sean Fleming on the tragedies that unfolded in the maternity services at Portlaoise hospital over several years. Much of this could have been avoided if the red flags that were raised on numerous occasions had been addressed. These were not red flags but alarm bells over governance issues ringing continually.

The executive summary of the report states:

This current investigation found that the HSE – as the provider of healthcare services – failed to take decisive action on defining the role of Portlaoise hospital and its model of care in the context of the findings of previous investigations. Corporately Portlaoise hospital viewed itself as a model-3 hospital and was not included in the national smaller hospitals framework. Similar to a model-3 hospital, Portlaoise provided a full range of acute services to patients presenting with all manner of injury and illness, including life support. However, at the time of this investigation, the HSE had failed to resource the hospital sufficiently and to ensure that the governance arrangements in place could safely deliver such a model of care to patients. For example, up until July 2014 the emergency department at the hospital – which was open 24 hours a day seven days a week – only had a consultant in emergency medicine on site for six hours, four days a week.

Earlier, I raised issues about accountability and who is ultimately responsible for this with the Taoiseach. I do not want to point the finger at or cast aspersions on any one individual. However, it seems there was an alarming problem with governance at local, regional and national level. The issue of accountability has to be addressed. We cannot talk consistently about systems failure. If we do not have accountability at senior management level, then we will have systems failure consistently because there will be no sanction for people who are simply not doing their job. I do not want to scapegoat any individual but there is an obligation on us to ensure accountability is part and parcel of the remunerative packages of people in charge and to ensure compliance with good governance.

Again, I extend my sympathies to the families who bravely challenged the HSE on this issue. I will have much more to say about this at the health committee over the next several weeks, as well as on the inability of the HSE to support the families and to be up front with the flow of information to families in times of bereavement and tragedy.

Leo Varadkar (Dublin West, Fine Gael)
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I welcome the opportunity to address the House on this matter. I want to begin by recognising the courage and fortitude of the patients and families who shared their stories. I want to thank them for bringing their experiences into the public domain. I hope the publication of this report brings them some small comfort. They have provided us with the opportunity to learn from the past and put things right for the future. This time I want to ensure the opportunity will not be missed.

Many aspects of the HIQA report disturb me. I am appalled that patients in the hour of their greatest need were not treated with respect, care and compassion. Patients and families were treated dreadfully and, at times, inhumanely. It is not all about resources. It costs nothing to care. Honesty costs nothing, neither does compassion. These patients and families needed to be supported. They needed to know that they mattered. They needed comfort. Instead, they got the cold shoulder. That to me is very unacceptable.

The fact that at HSE corporate level, patient safety and quality was not given the highest priority is also concerning. Patient safety and quality must be core to all we are and all we do. The report highlights an urgent need to embed a patient safety culture right through the health service. I accept the HIQA report in full and thank the investigation team for its work. The four recommendations made to my Department will be implemented. The HSE has confirmed that it too will implement the four recommendations made to it. I expect the HSE to implement an action plan to address the findings of the report without delay, certainly by the end of the year.

Improvements have been and will continue to be made at the hospital. New management and governance structures, both clinical and operational, are in place, including a new hospital manager and a director of midwifery for the first time, as well as an on-site risk manager. Since I have come into office, my priority has been to strengthen the hospital and address ongoing patient safety issues.

Appointments have been made to key posts in both the maternity and general services. This includes additional consultants in anaesthetics, surgery, emergency medicine, paediatrics and obstetrics. Up to 16 additional midwives have been appointed and approval has been given for further midwifery posts to include shift leaders and posts in diabetics and ultra-sonography. An ambulance bypass protocol is in place for serious paediatric cases.

Structural change has begun with Portlaoise now forming part of the Dublin Midlands Hospital Group. Any change to services in the hospital will be undertaken in a planned and orderly manner. This will take account of existing patient flows, demands in other hospitals and the need to develop particular services at Portlaoise in the context of overall service reorganisation within the group. Services that are viable will be safety-assured and adequately resourced. We will need to make sure services currently provided by the hospital that are not viable, due to insufficient case load or inability to recruit senior staff, are discontinued. Governance of the maternity service will transfer to the Coombe in line with the memorandum of understanding agreed already. I will also implement a national women and infants health programme modelled on the successful national cancer care programme, NCCP, to modernise our maternity services.

I will do everything in my power to ensure the recommendations in this report are implemented without delay. While we cannot undo the loss that patients and families have suffered, we can ensure lessons are learned and health services improved for all of us.

Seán Fleming (Laois-Offaly, Fianna Fail)
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I appreciate the Minister’s reply and accept his sincerity. He will appreciate there is no issue of this being a political matter. This is about people’s and young children’s lives, as well as patient safety. That transcends everything we do in this House.

One concern I have, however, is the Minister said the action plan will be implemented immediately and certainly by the end of the year. Between now and the end of the year, there will be 1,500 to 1,700 births at Portlaoise hospital. I do not think the Minister can say to those patients that by next year there will be a safe system in place. We need greater urgency than talking about the end of the year. Whoever is needed to come from the Coombe to the hospital, needs to be brought in now, not at the end of the year.

Due to the culture of HSE senior management at national level, if there is ever problem, it goes out to protect the organisation. Everything else is secondary. When recruiting for an operations director for the region some time ago, the Public Appointments Service specifically stated the director will be fully accountable and responsible for all services. The Taoiseach said something different here today. The terms and conditions of senior management need to have that stitched in to them. The Minister has an obligation to ensure that is done for all future recruitments into senior posts in the HSE, if it is not already the case.

Billy Kelleher (Cork North Central, Fianna Fail)
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The report stated: "The continued absence of a national maternity strategy as recommended by the authority in 2013 makes it difficult to assess and compare maternity services in Ireland". A national steering group was established on 30 April 2015, I assume on foot of the draft report. This indicates a lack of urgency in this particular area. As we have pointed out, there will be between 1,500 and 1,800 births between now and the end of the year at Portlaoise hospital.

The report also stated:

The pivotal appointment of a director of midwifery to a maternity department located within a general hospital is unique to Portlaoise hospital. This role has had a very positive influence in terms of assessing and improving the standard of midwifery care. However, at the time of writing, a senior obstetric lead had not been appointed to the maternity department to provide independent senior experienced obstetric clinical leadership.

Even as late as the publication of the report, some matters critically important for the delivery of safe maternity services at Portlaoise hospital had not been acted on. I would have thought at the very least an independent senior obstetric clinical leader would have been appointed forthwith.

Leo Varadkar (Dublin West, Fine Gael)
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I wish to clarify for the Deputy that actions have been taken to assure the safety of maternity services in Portlaoise. I do not think anybody waited for a report to do this. As the Deputy will be aware, actions have been ongoing for the best part of a year. The ones that may take a few months to complete include the establishment of an independent patient advocacy service which might have to be put out to tender. Legal status for the hospital groups will also take a few months to achieve.

We need greater personal accountability in the health service. It is not good enough to talk about a systems failure, which is an inadequate excuse. We need greater personal accountability. We also need to acknowledge where there are failures in the system. As things stand, two referrals have been made to the Medical Council concerning two doctors. There have been two referrals to the Nursing and Midwifery Board of Ireland concerning two nurses. There is an internal disciplinary process for HSE managers, although what is under consideration is appointing somebody from overseas to undertake disciplinary investigations of managers in the HSE because people may not have faith in an internal HSE disciplinary procedure. The point the Taoiseach made was that there were external disciplinary procedures for nurses, midwives and doctors but only internal procedures for managers.

It is important to point out that it is certainly not all about resources. Today I looked at hospital budgets. For example, the budget for the hospital in Portlaoise is within 10% of the budget for Naas hospital which covers a much bigger catchment area. Therefore, it is not all about budgets. Services were understaffed in certain areas, but to make them safe and bring them up to specialist standard, often no amount of resources will be enough because an adequate case load is needed to ensure clinicians are not de-skilled. One also needs to be able to attract specialists and senior staff, which is sometimes difficult. Up to now, where it has not been possible to attract specialists and senior staff, we have staffed services with expensive, often transient and not always very well qualified, locums and agency staff. That is happening all over the country. In the coming months and years we will need to consider seriously whether services that cannot attract specialists and senior staff should continue, not just in Portlaoise but also in many other hospitals all over the country. We need to face up to this issue.

The national maternity strategy group has been asked to report by October or November this year. One of the actions mentioned in the HIQA report is that a director of midwifery be appointed as midwifery services leader in every maternity unit. That will be done by the HSE. Notwithstanding the enormous financial pressure the State has been under and despite tough time, the number of midwives employed in the public health service is now 1,425. When the Government took office, it was 1,178. The number of consultant obstetricians and gynaecologists is at a record high. Despite the cutbacks made in recent years, therefore, we now have record numbers of midwives and consultants, even though the birth rate is falling. This shows that the Government takes the matter much more seriously than previous Governments, but we still have a long way to go.