Dáil debates

Tuesday, 1 December 2015

Topical Issue Debate

Hospital Investigations

6:10 pm

Photo of Marcella Corcoran KennedyMarcella Corcoran Kennedy (Laois-Offaly, Fine Gael)
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Will Members, please, clear the Chamber to allow for Deputy Micheál Martin’s Topical Issue matter to be taken?

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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Thank you, Acting Chairman. I thank the Minister for Health for attending the Chamber. Last week-----

Photo of Marcella Corcoran KennedyMarcella Corcoran Kennedy (Laois-Offaly, Fine Gael)
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I ask Deputies who are not here for the Topical Issue debate to leave the Chamber and not to talk.

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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If Members would not mind, as this is a serious and sensitive issue. There are people listening in the Visitors Gallery and a little decorum might be called for.

Last Tuesday evening, I had a meeting with a couple, Catherina and Stephen McGarry, from Sallynoggin, Dublin. On November 27 1991, 24 years ago, their daughter Jennifer Anna was born in the Coombe hospital. It was a forceps delivery and it went badly wrong. Jennifer Anna’s spine was badly damaged and just over ten weeks later, on St. Valentine’s Day, 1992, she died in her mother’s arms. Incredibly, her death was not reported to the coroner. In addition to this, Jennifer Anna’s brain and spine were removed from her body without the consent of her parents. Catherina and Stephen only learned of this in 2012, 20 years later. In 2009, the national audit of retained organs and post mortem practices occurred but they were not informed of it.

The Coombe hospital has now apologised in a somewhat qualified way to the couple over Jennifer Anna’s death. The hospital now accepts that Catherina should have had a caesarean section at an earlier stage. If that had happened, it is likely that Jennifer Anna would have been born without injury. It is clear too that she would be alive today. The qualified apology by the Coombe, while welcome, does not go far enough by any objective yardstick or for Catherina and Stephen McGarry. They want justice and accountability and are anxious that their daughter’s case be independently inquired into. They would also like a meeting with the Minister for Health to put their case.

They have written to the Minister on several occasions seeking a meeting but he has always refused their request. In a letter on 2 November last, they were told in a letter from the Minister, “there will be no further reply to correspondence on this matter.” I have read the hospital's report. I urge the Minister to reconsider his previous refusal to meet Catherina and Stephen McGarry and to meet with them at his earliest convenience. I also urge him to support their call for an independent inquiry and take steps to ensure such an inquiry takes place.

After the death of Jennifer Anna, Catherina and Stephen tried many more times to have children but had to endure seven miscarriages. They also tried to adopt but were rejected on grounds of age. This entire event has had an enormous and profoundly damaging impact on their lives. Catherina makes the valid point that if she did something wrong, she would have to be held accountable for it.

I understand the registrar who delivered the child using a forceps subsequently moved to the United Kingdom and that later, he resigned from a position in a hospital after concerns were raised about his treatment of patients. There are issues there to be inquired into. At the very least, an independent investigation is warranted in this case and that those involved and responsible be held to account.

At the very least, will the Minister meet with the couple to hear their case? It is evident that without the work Stephen and Catherina did themselves, we would not even have the report or the review that the Coombe hospital belatedly published in the past year. It is their work and persistence that has resulted in this matter being raised in the Dáil today and in the review being carried out by the hospital.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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I thank the Deputy for raising this case and for affording me the opportunity to offer my sincerest condolences to the family involved. The Deputy will appreciate that I have a no role in individual cases and do not have access to individual patient files or personal information.

I am informed that the Health Service Executive, HSE, and the Coombe hospital have been in contact with this family on an ongoing basis for several years and have apologised to them for the death of their child 23 years ago. In 2012, the Coombe hospital initiated a systems review to investigate the circumstances surrounding the death of an infant in 1992. This review, undertaken in line with the HSE's incident management policy and guidelines, concluded that there were deficiencies in care which contributed to the child’s death. It is important we learn from these adverse incidents as the single most important obligation for any health service is patient safety and improving the quality of care. That is why the Government is committed to improving the quality and safety of maternity services. A national women’s and infant health programme will be established by the HSE to drive improvement and standardise care across all 19 maternity units. The maternity strategy under development will provide the policy to direct and underpin the work of the programme.

There was also an additional €2 million provided to the HSE in 2015 to improve maternity services further and this funding provided for the appointment of additional staff, including additional obstetricians, midwives and other front-line staff. We will build on these improvements through the provision of further additional resources for maternity services in 2016, the detail of which will be set out in the HSE's national service plan.

6:20 pm

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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I am very disappointed with the Minister's reply. It is too cold. I asked him to meet the couple and he should meet them. They can inform him on why there are issues across the hospital system. He is saying he has been informed by the HSE and the Coombe hospital. The Coombe hospital has not covered itself in glory in regard to this case. There are fundamental lessons to be learned from this case alone and how the Coombe hospital dealt with it. As the Minister has put the Coombe hospital and the HSE in charge of what happens in the Midlands Regional Hospital, Portlaoise, so it has to be beyond reproach.

I acknowledge improvements which might have been announced today or last year and so on but this case was not even reported to the coroner. It was only reported to the coroner in recent months. That is very worrying. The apology is a qualified apology and the full story has not come out. There are issues in terms of what happened here. There are issues around the registrar. Did the authorities pursue those issues? Greater clarity needs to be brought to the situation as a matter of urgency.

Just because it happened many years ago is no reason to try to push it to one side and say, "I have been informed" and "I have no role in individual cases", because the Minister does have a role. I never said the Minister had access to files. However, when cases such as this one come to light, we all have a role. I could easily say I have no role. It was quite incidental that I came across the couple involved. I did not seek out the case to raise it in this House. I met the couple on a doorstep and they came to me months later and asked me to raise the matter here. The Minister should meet the couple. He may learn something through their experience about how the system works.

There should be an independent inquiry. What we have had so far is not an independent inquiry. The Coombe Hospital has not covered itself in glory in this matter and that needs to be revealed and lessons learned. Full accountability and answers as to why it was not reported to the coroner at the time are also required.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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The Deputy will know that I receive a lot of requests to meet patients and their families-----

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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So did I-----

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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-----as he would have during his term as Minister for Health and Children.

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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-----and I met them.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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I also do so on occasion. I have met the families in Portlaoise and Mr. Rowlette and Mr. Kivlehan. I met the patients' councils at Connolly Hospital, Blanchardstown, and Cavan Monaghan Hospital. I meet patients and patient groups all the time. There are, however, 2 million patient attendances in the public health service every year. If one goes back 20 years, that is 40 million attendances. It is not possible for me to meet everyone. I meet people where I have a particular role and can add something and there is a particular purpose to the meeting.

On the request for an inquiry or inquest, I am advised by the HSE legal services that this case must be notified to the current coroner and that no statute of limitations applies to the matter. Dr. Chris Fitzpatrick on behalf of the Coombe hospital has written to the coroner officially notifying him of the death. The coroner responded that he had received the notice and a decision on whether to hold an inquest will be made by the coroner, who is an independent quasi-judicial officer. I do not have the authority to order an inquest be carried out. It is a matter at this stage for the coroner.

Photo of Micheál MartinMicheál Martin (Cork South Central, Fianna Fail)
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The Minister could have a separate independent inquiry.

Photo of Leo VaradkarLeo Varadkar (Dublin West, Fine Gael)
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In terms of accountability, if there is a complaint against a particular doctor, the Deputy knows that the complaint is to be brought to the Medical Council. The situation is made difficult if the person is not in the State because no one in the State has the authority to act extrajudicially. If it is a criminal matter, a complaint would have to be made to An Garda Síochána.