Jack Chambers (Dublin West, Fianna Fail)
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I raise a matter of public importance, which is the need for the Minister for Health to establish an independent inquiry into the death of Malak Thawley in the National Maternity Hospital, Holles Street on the 8 May 2016. Representatives of the family have requested that I bring this emotional and personal matter to the floor of the Dáil.

Malak Thawley, who was living in Blackrock, was a 35 year old teacher who was expecting her first child with her husband Alan. An ectopic pregnancy was diagnosed at seven weeks and she required urgent surgery in the National Maternity Hospital. After surgery commenced, the abdominal aorta was torn by a bladed trocar. It took 55 minutes to identify this while an acute vascular haemorrhage was occurring on the theatre table.

A series of catastrophic and shocking errors then occurred. The consequence of these and the failure to follow basic protocol resulted in the death of Malak Thawley by medical misadventure as outlined by the verdict of the coroner. The significant cause of concern for the family, and for the public, is the contradictory evidence and information from the internal hospital inquiry and the facts as established by the coroner.

The hospital conducted an internal review of this tragic death by medical misadventure but following on from the considered and probative questions the family feels that crucial, vital and extremely revealing new facts, events and incidents have only now come to light. The family sees the internal hospital review as a shambolic attempt to hide crucial facts and salvage reputations. For public confidence, trust and transparency where serious adverse incidents occur we cannot allow hospitals to investigate themselves in this way.

There are a number of questions that illustrate the complete contradiction of evidence between the public coroner process and the internal review. Why did Mr. Thawley have to find out through a public forum that there was no blood in the lab, not enough blood in theatre and that his wife’s blood group was not cross matched? Why was there not enough staff to ensure basic functions such as having a laparotomy kit ready? Why were only junior staff available to treat Malak as she was dying? Why was there no supervision, no co-ordination and no accountability? Why was there a complete and total breakdown of communication at all levels? Why were staff not experienced in all forms of laparoscopy technique? Why did the hospital choose not to explain the difference between bladed and unbladed trocars in its internal investigation? Why was it never explained to Mr. Thawley that there was a recognised safer option of using the unbladed trocar? Why and how could it be that there was no consultant on site in the event of an emergency? Why did senior members of staff have their phones switched off or on silent? Why was it that ice for lifesaving cooling treatment had to be obtained from a nearby pub and why was this not explained clearly in the internal report? Why was there a lack of adrenaline available? Why did a Garda escort have to be arranged to procure other medical devices from another hospital? Why was there contradictory evidence provided by witnesses at the coroner’s inquest?

Some of the Minister's remarks in his correspondence to the family have disappointed them and while they acknowledge the Minister's expression of regret and sympathies, as the Minister for Health his correspondence referenced the future changes and the proposed move of the National Maternity Hospital to the St. Vincent's Hospital site. In the family's view this is completely irrelevant to Malak's case. In his correspondence the Minister stated to the family “perhaps the inquest into the late Mrs. Thawleys tragic death and the investigation in the hospital have indeed established what went wrong”. The family interpret these remarks as completely insufficient and an implication that the inquest may be the end to the matter. This will not address the internal hospital systemic failures, accountability, full disclosure, transparency and what can be learned to prevent similar tragedies in the future.

The family has two specific and direct requests of the Minister. The first request is for the Minister to meet with them. What is the delay to that happening? The second request is that the family want to be able to tell the Minister why they believe that an independent inquiry is absolutely necessary. The family want to tell the Minister directly. Will the Minister agree to establish a public inquiry in the interests of a maternal hospital system and in the interests of this very tragic case?

Simon Harris (Wicklow, Fine Gael)
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I thank Deputy Chambers sincerely for raising this issue and giving me the opportunity to again convey my sympathies to the family of the late Malak Thawley. While, of course, the death of any young person in Ireland is terribly sad, this is a particularly tragic case, as outlined by Deputy Chambers.

I understand that an inquest into Mrs. Thawley’s death took place recently and a verdict of medical misadventure was returned. Separately, the National Maternity Hospital has undertaken its own review of the case and in accordance with their clinical governance procedures. I also understand that the National Maternity Hospital has apologised unreservedly for the very significant shortcomings in the care of Malak Thawley.

I am aware that Mr. Thawley has requested an independent investigation into the circumstances of his beloved wife’s death. I assure Deputy Chambers this evening, and more important assure the Thawley family, that I am considering that request with the seriousness it rightly deserves. I shall set out to the House a number of decisions I have now made on foot of that request in order to ensure that I am fully informed and actions that I have communicated to Mr. Thawley through his solicitors earlier today.

I have asked Dr. Peter McKenna, the former master of the Rotunda Hospital, a very experienced obstetrician and the clinical lead of the newly established national women and infants programme, and his team to examine both the coroner’s report and the National Maternity Hospital report, and to provide me with a view on the appropriateness of the clinical reviews which have been undertaken to date. I believe this is the appropriate thing to do, based on Deputy Chambers's outlining of the family's concerns around the internal hospital review. Dr. Peter McKenna, the clinical lead of the newly established national women and infants programme, and who has also had a very long and distinguished career as the master of a maternity hospital, will carry out the review and will report back to me on the appropriateness of the clinical reviews undertaken to date and any potential shortcomings in them.

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I have also asked the national director of quality assurance and verification, Mr. Patrick Lynch, to examine how the National Maternity Hospital conducted the investigation into Mrs. Thawley’s death. I want to be assured that the review methodology was appropriate and that the review was undertaken in line with best practice. If that is not the case, I want to be advised as to what steps to next take. When these reports are to hand, I will be in a position to make a definitive decision. However, this evening I would like Mr. Thawley and this House to be assured that I have asked that these reports be completed without delay.

My Department takes very seriously the need to improve patient safety and, specifically, the need to improve the management of incidents. I have directed the newly established National Patient Safety Office to lead this work through new legislation, policy development and the development of a patient safety surveillance system. I should also mention that I have recently approved new HIQA standards on the conduct of reviews of patient safety incidents which will be launched shortly. These standards form part of a number of initiatives to improve the management of patient safety incidents. I am firmly of the view that we can make the system safer by listening and learning from incidents in tandem with ensuring that the patient and family are both informed and cared for by the system throughout. I can absolutely assure the House this evening that any lessons from Mrs. Thawley’s tragic death will be disseminated nationally by the national women and infants health programme.

In terms of the Deputy's first question, I have no difficulty meeting Mr. Thawley. However, as I outlined in my correspondence to his representative today, I still believe that there would be significant benefit in his meeting Dr. Peter McKenna, who is the clinical lead of the programme, a former master of another maternal hospital and the man that I have charged with reviewing this case and reporting to me. My aim is the same as the Deputy's aim and everyone else's aim, which is that Mr. Thawley would know the facts. I am happy to meet Mr. Thawley but suggest a meeting with Dr. McKenna first could be beneficial to him.

Jack Chambers (Dublin West, Fianna Fail)
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I welcome the Minister's final remarks but I think he should meet Mr. Thawley now. The family have asked it directly. They have gone through quite a traumatic experience with the hospital and in the Coroner's Court, where the evidence presented was completely contradictory to the internal hospital review. This raises serious questions. It was not any type of clinical review. We now know that a lot of the facts that the hospital claimed to have been established were inconsistent, incomplete, inaccurate, misleading and selective. Some of the recommendations from the report are meaningless because the facts as established in the Coroner's Court are different. For example, the internal review gave no recommendation about the issue with the ice that was aired in the Coroner's Court. This was one of the most descriptive and shocking developments in the Coroner's Court.

The Minister needs to listen to the family. They have been very direct about their request for a meeting with the Minister in order to outline why they believe an independent inquiry is absolutely necessary. They do not want any distraction or diversion by way of another meeting. The Minister should agree to meet them so that we can progress the matter. They have requested it repeatedly. They have serious concerns about this whole issue over the past number of months. That we have two seriously contradictory outlines of the elements and facts illustrates why the Minister needs to meet the family and why he needs to establish an independent inquiry. We cannot see that delayed by another process. While he might have a parallel process in train, the Minister should agree to meet Mr. Thawley and hear the serious concerns of the family.

These are concerns that might cause ripples through other aspects of our hospital system. This is one of the tertiary maternal hospitals. It had no ice. I do not have time to go through the detail of the internal report but it is absolutely shocking. This requires the full attention of the Oireachtas and this House. An independent inquiry is absolutely necessary, once the Minister has met the family. They are two simple requests. Will the Minister agree to the meeting?

Simon Harris (Wicklow, Fine Gael)
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I have given a very clear response to both of those requests. I have no difficulty meeting Mr. Thawley. I have said that clearly. However, I believe there is an advantage in Mr. Thawley also meeting the clinical lead of the national women and infants health programme. This is an eminent man with significant clinical experience in obstetrics. I have charged him, as the clinical lead of our national women and infants health programme, with carrying out a review of the processes that have taken place to date in order to advise me on additional steps. I consider that to be the appropriate approach for anyone holding the office that I hold, in addition to asking Mr. Lynch, who has a patient safety and quality role within the HSE, to look at how the National Maternity Hospital dealt with its own internal review of the situation. Within days of hearing Mr. Thawley publicly seeking further investigation into his wife's tragic death, I made requests of Dr. Peter McKenna and Mr. Patrick Lynch. I do not have a difficulty with meeting Mr. Thawley and do not wish to be interpreted in any way as having one. If he finds benefit in it, I have no difficulty with it. However, in an effort to help Mr. Thawley, I would hope that he and his family would engage with Dr. McKenna and his team.

As the Deputy mentioned it, and I am glad he did, I have heard from Mr. Thawley's representative on the issue of the co-location of a national maternity hospital. I do not wish in any way to conflate those issues. In fact, when I made my public comments in that regard, I said I was not commenting on an individual case. I was making the broader point that, in terms of our maternity services, it makes clinical sense to have them co-located with acute adult hospitals for times when medical care is needed. I do not make that point in any way in relation to this specific case. I very much take Mr. Thawley's request on board in that regard.

Again, I extend my sincere sympathy to Mr. Thawley and his family on the tragic loss of Malak Thawley. I am happy to meet Mr. Thawley. We just need to work out, in his interest, the optimum way for it to happen. All of our interests are in helping to establish all of the facts that Mr. Thawley wishes to obtain.