Mary Butler (Waterford, Fianna Fail)
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I offer my sincere and heartfelt condolences to the family of Thomas Power, including his wife Bernie, his parents, his sister and extended family. As we know, Tom was buried this morning. His death was very untimely. As the Minister, Deputy Harris, is well aware, considering that we have raised this several times in the House, that cardiac services in University Hospital Waterford are time sensitive. The cath lab opens from 9 a.m. to 5 p.m. on Monday to Friday. It is, therefore, open for eight hours per day and closed for 16 hours per day. It is closed all day on Saturday and Sunday. It is simply not acceptable that time restrictions play such a role in the day-to-day lives of our people. Cardiology intervention at University Hospital Waterford is time sensitive so if any patient presents requiring cardiac intervention outside the opening hours, his or her only option is an ambulance to Cork.

Last Sunday, Mr. Thomas Power, 39, recently married and expecting his first baby, presented at University Hospital Waterford with chest pains. A decision was taken that he should be transferred to Cork University Hospital. He died in Dungarvan, 30 minutes up the road. As I said, he was laid to rest this morning. The death has come as a huge shock to those of us living in Waterford and the south east. Unfortunately, it has not come as a surprise. Those of us campaigning for the second cath lab and for 24/7 cardiac care have warned for years of the dangers of transporting patients by ambulance for treatment. Dr. Patrick Owens, consultant cardiologist, has warned time and again that this would happen. It has happened. It is one death too many and it can never be allowed to happen again.

The Herity report has underestimated the impact of not having 24/7 cardiac care. It has underestimated the single-point-of-failure situation that we saw at the weekend. It has underestimated the commute time between University Hospital Waterford and Cork University Hospital. How can the Minister continue to stand over the Herity report?

David Cullinane (Waterford, Sinn Fein)
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The people in Waterford and the south east are angry and afraid. They are angry because of what happened to Thomas Power, who presented to the accident and emergency ward in University Hospital Waterford on Sunday with chest pains. He was suffering from cardiac complications. The cardiac unit, the emergency PPCI service, in the hospital was closed at the time. It closes at 5.30 p.m. from Monday to Friday and it is closed for the weekend. Rather than being admitted into the ward and treated by cardiologists, Mr. Power was put into an ambulance, in which he died 30 minutes outside Waterford.

A number of months ago, a number of regional clinicians and consultants met in Buswells Hotel in Dublin and robustly challenged Dr. Herity's findings. They said at the time that a decision not to enhance cardiology services in Waterford would cost lives. I spoke to those consultants today and they are livid. They are livid with the Department and HSE and they are also angry with the Minister. They and I accept that medical services should be provided on the basis of clinical and medical need but there is no justification whatsoever for people in a region with a population of 500,000 not to have access to emergency cardiac services out of hours from Monday to Friday and over weekends. Worse still, Dr. Herity recommended that all emergency services at the hospital cease. How is that report justified, therefore? How could it be stood over? We need a new review. Everything in the review is irrelevant unless it is based on the population of the south east. I sympathise with the family, to whom I have spoken personally. We have a job of work to do. I commend the Minister of State, Deputy Halligan, and Deputy Butler and all the regional politicians who work together on this. If there is a new review, will it be based on the population of the region?

John Halligan (Waterford, Independent)
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I too offer my condolences to the family of Tom Power. I believe that if he had taken ill on a Friday morning instead of a Sunday, he would have received cardiac intervention at University Hospital Waterford, which is about ten minutes from his home.

The Minister of Health and I have differed on the Herity report on a number of occasions. I respect that. He knows my firmly-held views that the calculations of the population were flawed and that it was incomplete on the basis that the experienced concerns and service needs of the consultants in south Tipperary and Wexford were not sought, despite the fact that there was a comprehensive input from the consultants in Cork. Crucially, in the context of the death of Mr. Tom Power, the review did not address life and death clinical risk and safety concerns. Pre-dating the Herity review, the HSE itself identified the lack of the second cath lab at UHW as being an extreme clinical risk under the HSE risk register. That status was downgraded by an unknown person in the HSE prior to Dr. Herity commencing his review. After the publication of the Herity report, further suggestions of interference in the review process emerged. I believe that Dr. Herity was given flawed and biased information prior to commencing his work. A briefing note prepared by unit 3 of the Department of Health explicitly stated that the second cath lab was not a priority. It is my belief that the interference has continued.

I commend the Minister on the work that he is trying to do at present by formally approving the deployment of a mobile cath lab on 8 May. However, it was not until 12 June - five weeks later - that the Department of Health formally instructed the HSE to proceed to tender and notify the management of UHW. For five weeks, I believe that a ministerial order was completely ignored. For five weeks, the Minister's express instructions were treated with utter contempt by civil servants. This is not fair to the Minister. I believe that the HSE is a law unto itself and that unknown person or persons within the HSE are determined to put every obstacle possible in front of the expansion of the cardiac services in UHW. I believe there is an agenda playing out that the extension of services at UHW has nothing to do with the clinical need.

Pat Gallagher (Donegal, Fianna Fail)
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Go raibh maith agat.

John Halligan (Waterford, Independent)
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The presence of the mobile cath lab would not have saved the life of Tom Power. However, there will be more Tom Powers and more lives needlessly lost unless cardiac services in UHW are expanded. This will never happen while we, the elected-----

Pat Gallagher (Donegal, Fianna Fail)
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The time has expired.

John Halligan (Waterford, Independent)
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----representatives of the region, are fighting against an invisible force within the health service.

James Browne (Wexford, Fianna Fail)
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I begin by expressing my deepest sympathy to the Power family, to Thomas Power's wife and to her family, the Delaney family of Murrintown, County Wexford. Mr. Power's death is a devastating loss to his family.

The death of Thomas Power is a heart-rending reminder of the desperate need for 24-7 cardiac services in the south-eastern region. More than half a million people live in the south east. The existing cath lab is the only one that operates on a part-time basis. It is difficult to see how this is justifiable. How can it be that when patients reach the largest hospital in the south-eastern region, a university hospital, they cannot be given the basic services that are necessary to keep them alive? How can anyone stand over the fact that someone with chest pains who present him or herself at UHW before 5 p.m. on Friday is treated any differently to someone who presents after 5 p.m. or at the weekend? Why are those people made to risk their lives by having to travel to Cork?

Take my own county of Wexford for example. The popular village of Fethard-on-Sea down in New Ross is 180 km from Cork University Hospital. That is almost three hours of travel time. How could anyone be expected to survive such a distance? There have long been warnings of the risks of not having 24-7 cardiac services in Waterford. These risks are posed by outsourcing cardiac patients down to Cork city. It is simply indefensible. The people of the south east are being treated as second-class citizens. It is difficult to see how anyone can stand over a region of half a million people not having access to 24-7 services.

I appreciate the Minister realising the Herity report, but that report ignores the real consequences of restricted cardiac services for the south east. How can the State guarantee patient safety when critically ill patients present themselves at a hospital and are then expected to travel to a second hospital 130 km away? It is not rational, acceptable or right. A second review needs to be carried out on this situation.

Simon Harris (Wicklow, Fine Gael)
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I thank the Minister of State, Deputy Halligan, Deputies Butler, Browne, Cullinane, my colleague from the region, the Minister of State, Deputy John Paul Phelan, and from the other House, Senator Coffey, who have all raised this important issue of cardiology services at UHW. I too was very saddened to hear of the tragic death of a young man, Mr. Power, who was being transferred between two hospitals at the weekend. I offer my sincere condolences to his family. I think it is important that we are sensitive to their needs at this time. As Minister for Health, however, I cannot comment on individual cases and so will address the House on the wider cardiology service issue, except to say that I expect all the proper procedures will take place with regard to the circumstances of this tragic death. I believe that is important.

Last year, in line with a commitment in the Programme for a Partnership Government, an independent review of the need for a second cath lab at UHW was undertaken by Dr. Niall Herity, a world-renowned cardiology expert. The review concluded that the needs of the effective catchment population of UHW could be accommodated from a single cath lab. However, the review also recommended increased investment to enhance cardiology services at the hospital and to provide an additional eight hours cath lab activity per week to address waiting times and provide improved access for patients.

At the time of the publication of the report, I committed to providing those additional resources to the hospital. I did so. The HSE national service plan 2017 subsequently identified the implementation of the recommendations of the Herity report as a priority and additional funding of €500,000 was provided for the hospital. I should also mention, as the Minister of State, Deputy Halligan, alluded to, that the HSE issued a tender this week for a mobile cath lab that will contribute on an interim basis to a further reduction in elective cardiology waiting lists in UHW.

I also committed to a further review to assess the impact that these improvements have had on the volume of patients attending the cath lab and this review will take place at the end of the deployment of the mobile lab. I commit to keeping Oireachtas colleagues from Waterford and the region briefed on plans for that review.

With regard to emergency work at the hospital, I want to stress again that all decisions on how we configure our health services must be evidence-based. I think everybody accepts that and I appreciate that. Dr. Herity recommended that emergency work should cease in order to allow the hospital to focus on the much larger volume of planned work and to contribute to improved patient outcomes. That was the finding of the independent review. I believe it is fair to say that the organisation of primary PCI services is an issue for the whole country. It relates to how we provide services to our whole population taking account of the best evidence available. While we are discussing Waterford and the south east today, it is indeed an issue beyond just the south east. I would point out that patients in Monaghan are transferred to Dublin for primary PCI and patients in parts of Kerry go to CUH. Highly-specialised services such as primary PCI need to be carried out in a small number of hospitals around the country where the volume of patients supports the provision of a safe service. Low-volume services do not facilitate the ongoing and sustainable achievement of the patient outcomes required. That has been the long-held clinical view.

Based upon this country’s population, we can only operate a limited number of primary PCI centres in order to ensure that services achieve required standards and are sustainable. Clinical staff cannot maintain their skills where volumes are insufficient and staff will not be attracted to work in units that do not facilitate them producing the outcomes expected.

I believe it is time for a full national review of primary PCI services. Therefore, I have now asked my Department to make arrangements for this national review to be undertaken based upon independent clinical expertise and this will obviously include the south east of the country. This review will seek to ensure that as many patients as possible have access on a 24-7 basis to safe and sustainable emergency interventions following a heart attack. The review will therefore address the wider implications for all services and all parts of the country of Dr. Herity’s view regarding primary PCI services and will come up with a plan for the achievement of the best patient outcomes possible. Clinical safety is paramount as part of that review.

I want to repeat that extra investment is being provided to allow additional activity at the existing cath lab. The mobile cath lab is confirmed for Waterford and is on the way. There will be a further review of UHW's situation following the deployment of this mobile Iab. I will consult with Waterford Oireachtas Members at that stage with regard to that review. In addition to that, there will be a national review recognising the importance of access to PPCI services for all our citizens.

Mary Butler (Waterford, Fianna Fail)
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I thank the Minister for his answer. I welcome the fact that he has said that it is time for a full national review of primary PCI. Unfortunately, since five o'clock this evening, the cath lab is closed in Waterford while we are here discussing it. If another Thomas Power presents, we are still going to have the same issue. I ask that there would be no interference from the HSE with regard to the terms of reference for this report. Clearly, as the Minister of State, Deputy Halligan, pointed out, there was interference the last time. We all saw copies of the letter and the dictat issued. That cannot happen again.

With regard to the extra investment, the Herrity report was published in September 2016. I spoke to management in the hospital before I came here. Not one extra hour has been put in place. The hospital is only advertising for staff now. Those extra eight hours would be very important but they need to be in place as soon as possible. The only solution is a second catheterisation laboratory and I will be sticking to my guns on that.

David Cullinane (Waterford, Sinn Fein)
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I am sure officials in the Department wrote the Minister's script. His response worries me because he is saying that highly specialised services such as primary percutaneous coronary intervention, PCI, need to be carried out in a small number of hospitals. He said that low-volume services do not facilitate the ongoing and sustainable achievement of the patient outcomes required and that based upon this country's population, we can only operate a limited number of primary PCI centres. We are being teed up again for a report that will again tell us the same thing. That is what I am reading from this because I have seen the documentation. I received it under a freedom of information request. The HSE, the Department, the acute coronary syndrome programme and the South-South West hospital group were all saying the same thing, which is that the population of Waterford and its environs does not justify emergency PCI. Unless the Minister accepts that this is regional and unless the terms of reference are very clear that this is about the south east and the population of the south east, which is what was in the Higgins report where a clear commitment was given that enhanced cardiology services and interventional cardiology for all 500,000 patients in the south east would be provided at University Hospital Waterford, it will be a tee up by officials in the Department and the HSE. We have been sold pup after pup on this issue and enough is enough. While the Minister says he will consult, unless he agrees today on the regional nature of this issue, it will go nowhere and we will continue to be sold down the river time and again.

John Halligan (Waterford, Independent)
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Members of the Independent Alliance and I had a meeting with the Minister today. Outside of the national review, there is a commitment to a review in the south east, which will cover all of the south east. The last review did not cover all of the south east. I take into consideration what Deputy Cullinane is saying but I ask Members from the south east to meet with the Minister and me as we sit down to decide the terms of reference for this review. For the first time ever, Members of the Oireachtas from the south east will have a say in how this review will be conducted. I am convinced that if the regions that were not taken into consideration in the first review - the consultants in Wexford, Tipperary and so on - and the catchment area whose inclusion we will have a say about are included, the catchment area alone will carry the review over the line, which did not happen the last time. I had a fruitful meeting with the Minister. We do not always get on and we have our differences but I think there has been a change. Let us get Members of the Oireachtas from the south east and the Minister together and see whether we can push this review over the line.

James Browne (Wexford, Fianna Fail)
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We know about one death because it occurred on the road to Cork but how many people have made it to Cork only to die subsequently because it took them too long to get there and how many people have suffered additional heart damage as a result of a delayed arrival in Cork? The south-east region needs 24-7 cardiac care. It has the population 500,000 people but it also has large populations in geographically isolated areas. I mentioned Fethard-on-Sea in County Wexford. Other areas include Ramsgrange, Kilmore Quay and Our Lady's Island. They are highly populated areas with high numbers of tourists yet they are up to three hours away from Cork. It is simply not acceptable to say to those people in the south of Wexford, Waterford, Carlow and Kilkenny that they must travel to Cork to get services to which everybody else in the country has access. A region with 500,000 people should have 24-7 cardiac services in its top hospital.

Simon Harris (Wicklow, Fine Gael)
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I respectfully say to Deputy Browne that he is wrong in suggesting that everybody else in every other part of the country has access to this on their doorstep. That is not the case. I referenced two examples - Monaghan where people must travel to Dublin and parts of Kerry where people have to travel to Cork. There are a number of places in this country that are outside the 90 minutes and that is why-----

James Browne (Wexford, Fianna Fail)
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Not an entire region.

Simon Harris (Wicklow, Fine Gael)
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Well people are people and citizens are citizens. We need to ensure that every citizen in this country can access services. I am not making a partisan point but Deputy Cullinane made a number of what I view as potential slurs on officials in my Department and the HSE. I stand over their integrity as hard-working public servants. The Deputy might know-----

David Cullinane (Waterford, Sinn Fein)
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No slur was made against anyone. The Minister of State, Deputy Halligan, made far stronger allegations against the Minister's officials.

Simon Harris (Wicklow, Fine Gael)
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My officials do their job to the best of their ability in accordance with all good practice in the public service. It is the same position as that held by officials in Northern Ireland. If Deputy Cullinane asks the leader of Sinn Féin in Northern Ireland, who was a good colleague and counterpart of mine as Minister of Health, he will discover that the same procedure applies in respect of primary PCI in Northern Ireland. I would not like it to be interpreted as a view in the Department or the HSE. This is a long-established view on the island of Ireland regarding access to primary PCI.

Leaving that aside, I am committed to doing the four things. The additional investment has been provided. The point made by Deputy Mary Butler is valid. Management now needs to get on with expending that investment and putting those additional hours in place. The mobile catheterisation laboratory is on the way. When both of those things are in place, it makes sense to have a further review to see what the additional impact of the extra hours is in terms of the number of people using the catheterisation laboratory. I think this is logical. At that point, I will engage with Members of the Oireachtas in the south east. I genuinely welcome that engagement.

The fourth thing I am doing is talking about a national review because there are parts of this country where we need to make sure the spread of our primary PCI structure is at an optimum level for all our citizens. I have instructed my Department to commence that national review and will keep in touch with Members of the Oireachtas.