Mary Butler (Waterford, Fianna Fail)
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This is my tenth year speaking in the Dáil and representing my constituents. There have been tough days where I had to stand up and one of them related to the Maskey report on mental health. Today is another one of those days when we discuss unnecessary hip surgeries in Children's Health Ireland, CHI.

The patients and families affected by the publication of the audit report are at the forefront of my mind, as they are for every Deputy. I understand the frustration, anxiety and, indeed, anger the families and these children and young people will be feeling as they read through the report and consider its findings.

There is no doubt parents will be questioning themselves, wondering if they did something wrong and questioning the trust they placed in the doctors to care properly for their children. Children’s Health Ireland and the clinicians that work there have a job of work to do to restore and rebuild trust with children and families. We can all have our say on all sides of the House but what matters most, and what is most important for me, is the families get answers to all the questions they have arising from the report.

The Minister for Health has directed a strong and urgent response to the report with the children, parents and families at the centre of the response. Children’s Health Ireland needs to now continue to respond without equivocation. I note the apology from the chief executive that families were not offered one consistent and excellent standard of care and that children were simply let down. CHI is acting swiftly to provide answers to patients and families. It is important to highlight that clinical follow-up is under way for children who have had these procedures. This has to be the immediate priority and I welcome that these patients are front and centre.

I also welcome that letters are being issued to families and that appropriate follow-up arrangements will be put in place, taking into account each individual case, the age of the child and where he or she had his or her surgery. We cannot leave patients or their parents questioning something in a letter or unsure if the latest piece of information actually relates to them. I was shocked to hear, even though I only heard it anecdotally in the House today, that in the letters it has been requested only one parent attend with a child. That is absolutely appalling and we will have to rectify that. Parents must be facilitated in the communications under way with families regarding arrangements and next steps currently available to them. Their questions must be answered and they must be able to trust and rely on the health services in place to treat children.

It is crucial families are updated and communicated with in a transparent and timely manner and their worries, questions and feedback are listened to closely as the response to this issue rolls out. The important question still remains for parents of whether the surgery their child had met the proper standard. That question must be answered for each and every person who asks and it must be answered by the clinicians and not us as politicians.

I look forward to hearing further from the board and executive of CHI on implementation of the recommendations in an open and transparent way.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I welcome the opportunity to update the House on the response under way following publication of the clinical audit into developmental dysplasia of the hip, DDH, surgery on children in CHI and National Orthopaedic Hospital Cappagh, published last Friday, 23 May. This follows on from our debate on 29 April where we said we would revisit this and it is appropriate we continue to work on these issues together in the coming months to address our shared concerns and to move to a place where we have better confidence in the clinical governance and decision-making in certain parts of CHI that have presented repeated difficulties for patients.

Parents and young people themselves will have many questions when they read the report, and the findings of this report will lead to worry and uncertainty for them. Like many Members, I have met and spoken with parents whose children had these surgeries and I know their worry, as do my colleagues in this House. This experience of worry for your child and of being completely in the hands of a clinician, their advice and decisions is one those who have not experienced it perhaps cannot understand, in particular, the depth of concern. In that vein, I respond today and other days to all the issues in CHI we face together in this House as the current Minister for Health but also as the parent of a child in the long-term care of CHI.

I hope the actions we now take will help in that process, although I recognise the volume of cases mean it will be some time before everyone has a resolution to their satisfaction. I am not happy about this but please let me take the House through the actions to be taken, the backdrop against which they will be taken and where we will need to go together for the future.

The actions I am now taking will ensure better improvements: first, in implementing the clinical recommendations of the audit to prioritise patient’s follow-up care; second, in establishing an independent and external expert panel to lead a retrospective review of individual cases to determine the appropriateness of the original decision-making for performing the pelvic osteotomy; and, third, in taking steps to strengthen governance and oversight in CHI as we move to a longer-term perspective. My immediate priority is to ensure there is clinical follow-up and care for patients who have undergone this surgery. This follow-up will be in accordance with best practice and the recommendations of the report.

Deputies know an information line was available over the weekend. This is an information signposting for parents in the first instance. I appreciate this does not answer every question - nor can it - in that effort to try to provide signposting. What parents need and what they will receive is letters from CHI and Cappagh hospital about the arrangements and next steps that individually apply to them and their child and how they will get further information or support. I expect these letters to be accurate and personalised. While Deputies will appreciate I do not sign off on every letter, I assure them I have said to both these institutions that I expect that standard to be there for these letters.

I recognise that the wait for the letter is difficult in itself and I do not want parents getting wrong information of any kind.

I have been informed that clinical follow up to skeletal maturity in CHI Crumlin is already under way for 447 patients. Many of whom, about 200, are almost at skeletal maturity and will likely need just one more appointment. Clinical follow up is also under way for CHI Temple Street and Cappagh patients. These children have been identified and categorised by age. That encompasses approximately 1,800 children, a proportion of whom, 392, as I understand it, are close to skeletal maturity. It is planned that a multidisciplinary team, including physiotherapists and nurse specialists and overseen by a consultant surgeon who is appropriate, will be involved in this clinical review. It is also important to recognise the transition of care for patients who require follow up by adult services will be agreed. A new model of care for all children who have undergone and will undergo these surgeries will be implemented, generally involving review at five, eight and 12 years post operation.

Deputies are already aware that a cross-site pre-operative surgical meeting is already in place since March 2025. We discussed this in April. All children are being discussed at this meeting before they are listed for surgery by any of the services concerned. This, along with contacting parents whose child may be impacted by this audit, were, I am told, the two recommendations the auditor made to CHI when he provided a draft of this report in March. I am told CHI was informed that these were the only two recommendations that were available and definitely would not change, pending the publication of the report.

In respect of a retrospective review, of course what parents will want to know is whether the surgery their child had was appropriately clinically indicated. Patients and parents are entitled to know and there will be retrospective review of their case to determine the indications for surgery - was it needed or how was it in line with standards at the time it was indicated. This is separate from the clinical follow up process. It is a separate and additional process, involving a panel of independent external experts, and it will be established for this purpose. It will not be connected to CHI. This panel will comprise radiologists and paediatric orthopaedic surgeons and will be chaired by an international expert. Professor Deborah McNamara, president of RCSI, has agreed to assist the HSE in establishing the expert panel.

Today I brought a memo to Government to set out the high-level terms of reference for this review. The review will have the following objectives: to provide individualised case reports for each of the cases affected; to provide an overall collated report; to provide expert opinion, insofar as possible, on individual cases of potential implications where it was identified that a procedure was not necessary - I will ensure Deputies have this to hand; to have due regard for the criteria as set out by Mr. Thomas within his report and the criteria being developed by the expert reference group; and to document the final suite of criteria against which the original surgery will be assessed. In conducting this review, the experts will be cognisant of the historic nature of the work and will be aware of confirmation and hindsight bias. The terms of reference cannot be finalised until the review panel is some way in place. I want to make sure they are comfortable with the terms of reference. I have taken it as far as I can and I need the opinion of the expert panel on its terms of reference, as the Deputies will understand. Obviously, parental consent to participate in the review will be required. I suspect parents will be actively seeking this review rather than us asking them to consent to it.

This will take a little time, both to bring together the panel and to complete the reviews. This is a recommendation of the report which we received on Thursday last and published on Friday. I know Deputies across the House have criticised this not already being in place but, as I said in April, I can only go on the detail of the report as it is presented to me. I received the report on Thursday last at 4 p.m. It was published in full, as I said it would be - redacting any personal information, which, as it turned out was not necessary - at 1 p.m. on Friday. The terms of reference and follow-up process are now agreed by Government and the outstanding piece is the independent experts. I assure the House I will move with the same pace and urgency on that matter as I have, I hope, with other matters.

I want to be clear about accountability and governance-response issues. It is correct, as Deputies in the House have already done, to look at the systemic and structural issues we will discuss shortly. However, I want to take a moment to recognise that we are having this series of debates because of the decision-making of individual consultant surgeons, whom the audit and the HIQA report have said were not operating in line with international practice and whose explanations for those operations were not accepted by the auditor. In the HIQA report, we were responding to a series of decisions that a surgeon made that led to them using surgical springs in the bodies of small children. We have to ensure proper clinical governance and accountability. However, I do not want our focus on that to detract from the individual decision-making and individual accountability that is appropriate for the individual surgeons making decisions about small children.

Related to this, on the broader governance issue, I have said a number of times that I am trying look at this question in relation to the broader governance of CHI in a way that enables the functional continuity of CHI, both to respond to the various patient needs and the issues we are discussing, the broader running of the paediatric system and to move us towards opening the new hospital. I want to ensure we see the appropriate governance structure in place to make sure that we have clinical leads who are managing each team, as I said in April after the publication of the HIQA report. I want to make sure every consultant who is employed in the State knows they are not a single fiefdom, that they work within a hospital system, that they are public servants paid by the taxpayer and that they follow rules set out by us in an appropriate governance structure.

I want a culture, as I have said before, where people who see things that are clearly wrong not only can step forward and say that but must step forward and say that and be afforded the appropriate protections. In that vein, I particularly want to thank the whistleblower in this context who brought this information to light. I respect the work the whistleblowers have done in this case, as they have done in other cases. I hope we will work together on this, and I am sure we will, but I am trying to undertake a transformation process in a steady way. However, I do not wish that to be interpreted as ignoring the importance of any of these issues. I am trying to manage this in a steady way.

CHI was established in 2018 under the Act to bring together three historic hospitals under a single roof. Differences and cultural problems manifested themselves in different ways over the period but the concept of a single paediatric system is now well settled, even if sometimes some people need a little reminding. The board is an unusual construct where four members, as I have said before, are appointed by the Minister. Eight are appointed by the board itself, coming from the nominations of the old historic entities that were brought together to CHI. The board itself appoints the chair. There have been members of the board dating back to 2018, including until recently the chair and there are other members appointed this year or last, so there are two very different sets of institutional memory and institutional experience.

Deputies will be aware that in April the chair stepped down and since then a total of four other members have stepped down, all of whom were appointed in 2018, I believe. This afternoon I referenced on radio that I had received three resignations this morning but I did not reference, and of course should have, that a fourth had stood down last week. My apologies for my oversight in that regard. It was certainly not intentional. I thank them for their contribution. We have to think about public appointments and public service generally. We are asking these board members, for CHI or other entities, to serve the public interest. They are not professional clinicians but they are people who are broadly committed to public service. I am not by any means excusing individual actions. I am simply saying that it is in all of our interests that people continue to want to perform public service. That is why I am trying to separate out some of the issues from the decisions of individual clinicians. These things should not be conflated. However, I think it is true, as I have said in different ways before, that it was important in the case of CHI that while the experience of the board setting up in 2018 had very serious and difficult work to do, it is now appropriate that their experience is brought to a point where a refresh is appropriate. I take the next steps with the following purpose.

I have moved immediately to strengthen governance and oversight structures at CHI and Cappagh. This will be done by the appointment of two members of the HSE board to the board of CHI. I have already done this. That was before I received these additional resignations. I now have additional vacancies, which I will reflect on. Regarding Cappagh, I have also asked the HSE CEO, Bernard Gloster, to consider the implications of the audit for Cappagh and its oversight of paediatric surgery conducted at the hospital. The CEO has agreed to do that and to respond in the coming days.

At operational level, there will be a strengthening of the service level agreement between CHI and the HSE to strengthen operational oversight, and increased involvement and support from the Dublin and midlands region regional executive officer and senior management. That is designed to support the new CEO, Lucy Nugent, in CHI and enable her to continue with the transformation programme she has begun. Ms Nugent has been in post just since February and is in the process of establishing a new executive team around her to lead this next stage for CHI in the way we want to see it done. She reports to the board and needs a functional board to be able to function.

7 o’clock

It is in nobody's interests to move things too rapidly. There does need to be a functional board, although it is clear that I want it to move in a particular direction. My appointments to date have signalled that direction.

I have said, as I referenced previously in this House, for example, on 9 April, the day after the publication of the HIQA report, that I am open to looking at the governance of CHI in the round. I said that we need to have a functional system to be able to work towards the opening of the national children's hospital. I also said that I am open to looking at everything in the round, but that I would like to receive the other two reports first. Some weeks later, it is now clear that we have a very different board to the one that was there when I took office and, much more importantly, when these events occurred. Second, I have clearly said that I want to see an appropriate clinical governance structure. What this means is that consultants work to a clinical governance structure from which they take direction and to which they are accountable.

Earlier today, I met with the Attorney General to discuss my next steps in relation to the board, clinical governance structures, broader governance issues and how CHI interfaces with the HSE, recognising that the HSE funds CHI. I will take a steady approach to this. I welcome all perspectives from Members of this House about the desirable outcome and the steps to get there while enabling the continued functioning of CHI.

I want to facilitate the Minister of State, Deputy Murnane O'Connor, in contributing to the debate. While we are discussing hip dysplasia, it is very important that I update the House on an internal CHI report that was covered in the media on Sunday. That report was provided by CHI to the CEO of the HSE on Monday, 26 May, and I also received a copy from the HSE on the same day. Yesterday evening, I wrote to the board of CHI requesting a full response to the report. I wrote a detailed letter asking specific questions and I reserve the right to write further letters. I need to receive the response but, on its receipt, my officials will follow up to address outstanding risks or concerns where they still exist.

In addition, the CEO of the HSE is commissioning an audit of governance and equity in patient access and waiting list management at CHI. The audit aims to assess governance and equity in access to care, especially regarding the balance between public and private patient management. I will consider further responses to the issues around waiting list management and the NTPF raised in the report. I have also asked the NTPF for its perspective. We are mandating centralised referral to all CHI surgical services in order that all GP referrals will be processed via a central system, enhancing transparency, equity and efficiency, with the aim of ensuring patients are cared for based on clinical need and to increase effective management of waiting lists.

I tried to leave as much time as possible to take questions throughout. We will speak about this matter again very shortly at the Oireachtas committee.

Jennifer Murnane O'Connor (Carlow-Kilkenny, Fianna Fail)
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I begin by acknowledging the anxiety that many young patients and their families will be feeling this week as they read the report's findings on surgery for children with developmental dysplasia of the hip across CHI and the National Orthopaedic Hospital Cappagh. I can only imagine the distress and upset the families are experiencing. There is clearly an urgent need to establish why so many children received surgery when they did not need it. There must be accountability.

I thank Mr. Thomas, the expert auditor, for his work on this report and for the recommendations he has suggested. The audit report and its recommendations have been accepted in full by CHI, Cappagh and the HSE, and the important work to implement these recommendations is already under way.

I accept that families still have many questions about their individual child's surgery, and are seeking answers on what the next steps will be for them following this audit. The first priority will be to recall all the children affected by the audit for a clinical review, to see how they are doing now and to make sure they do not have any complications from the surgery. It is critical that they get proper follow-up to the age of skeletal maturity, when their bones are fully grown and developed, which is typically between the ages of 12 and 16. Parents are due to receive personalised letters from the hospitals in the coming days about this.

Processes have also been put in place since March to ensure safeguarding. All DDH cases are being reviewed by a single team, involving clinicians from all three sites, before any decision for surgery is made.

Parents still have questions about whether their child's surgery met the proper standard, and the Minister is putting an expert panel in place to deal with this. Parents will be informed about the details of the process shortly.

I am mindful that there are other relevant processes ongoing that are awaiting completion, the learning from which will feed into the future development of services. It is important that there is fundamental reform at CHI to ensure a multidisciplinary approach across all areas of medicine for which it is responsible. Patients and their families must have trust and confidence in the care they receive.

A commitment has been given that the work is ongoing. The Minister and the Minister of State, Deputy Butler, are working with the Department on all necessary matters in order to get this sorted. I am grateful for the opportunity to provide an update.

David Cullinane (Waterford, Sinn Fein)
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The Minister will agree that the cornerstone of our health service is trust. I am not a clinician, and I do not think she is one. Although some are clinicians, most Deputies in this House are not, but we depend on clinicians to guide us when we develop specialist services, for example, and when we get sick. That came into very sharp focus during Covid when people tried to sow mistrust about clinical advice. I have always been of the view that if I get sick, I go to my GP, thank you very much, for medical advice. We put our faith in the medical fraternity. That is what we have to do. When that trust breaks down, however, it is very difficult and challenging. Trust in Children's Health Ireland is shattered, in particular its orthopaedic services. That is unfortunate, but how could it be any different when we look at numerous reports that have cited governance failures, management failures, clinical failures, ethical failures, conflicts of interest, failures relating to open disclosure, and many more failures right across the system? That creates real problems for Children's Health Ireland.

The Minister is new to her post. I have no doubt she is trying to respond to this in the best way she can, but it is not an issue that just dropped into our laps in recent weeks. In fact, I imagine there are parents and advocacy groups watching and listening to this debate that quite rightly say they also blew the whistle on many of these issues for many years. They feel betrayed because they met with what they would describe as a wall of silence - a brick wall. I know the Minister met some of the advocates and parents in recent weeks. I met them several times. They raised issues relating to governance failures, clinical failures, management failures, ethical failures and many other issues for years. I listened to them and raised some of their concerns in this House, as did my party leader and others, including Deputy Paul Murphy. Unfortunately, they were not supported, or at least they say very directly - we must be conscious of their experience - that they did not feel supported. I just make the point to the Minister that these are not new issues.

Unfortunately, there are various issues involved. Very recently, we had a report from HIQA on the use of non-medical grade springs. In its own right, that was a shocking report. It pointed to very serious clinical failures by a clinician. That person must take responsibility for their actions. The report also cited very clear process failures, management failures and other failures in Children's Health Ireland, which have wider implications beyond the use of non-medical grade springs. In speaking to the Minister, I referred a number of times to one line in the report that was most damning. It was that children were not protected from harm. If that was the only issue in Children's Health Ireland, as bad as it was, then we could deal with it, but, unfortunately, that was not the case.

As the Minister is aware, we also have a clinical review into surgeon A – I am not sure whether it is only one surgeon involved - who was at the heart of the issues in relation to the use of non-medical grade springs. That person's clinical practice is under review by Dr. Nayagam and perhaps others as well. Dr. Nayagam was looking at very unusual patterns of high rates of return to surgery, infections and other issues. We still have not received that report. We must wait until the report is completed, but I have no doubt that it is going to point to very similar issues and patterns in respect of clinical failures and governance and management.

Then we had the leaking of the audit into hip dysplasia and osteotomies carried out on children. That was published by The Ditch. It was not picked up or covered all that much, even though it was being raised in the Dáil and many of us saw it as a very serious issue. Of course, it was only a draft audit. What was in that audit and what was published, however, was very worrying. I assume it was a whistleblower who put it in the public domain. We have all commended the whistleblowers in Children’s Health Ireland who have come forward, and I have met some of them in recent years.

Very quickly after that audit was leaked and arrived on the website of The Ditch, 2,200 letters were sent out to families. Parents are very worried, anxious and angry for a range of understandable reasons. They are worried that an unnecessary operation or procedure could have been carried out on their child. That would be cruel, particularly when we consider the stories we have heard about children who have had to learn to walk again after these procedures and those who were put through surgeries that are painful and difficult for any child. I have two children. One is 18 and is now an adult, but I also have a 14-year-old. I can only imagine that if any of our children had a procedure that we felt was unnecessary, for whatever reason, we would be devastated. That devastation is very real for the parents involved.

Again, we do not know why. Parents ask me, not just about this issue but also in the context of all of these issues, how this was allowed to happen. How is it that the surgeons failed? I accept that not all of them failed. I want to put on record that there are many brilliant surgeons and staff in Children’s Health Ireland. I have said this publicly. My heart goes out to all of the great staff working in Children’s Health Ireland who do such a fantastic job. However, there are those who have failed and they have to take responsibility for that.

Others failed as well. The Minister talked about members of the board and about wanting to be careful and cautious. She said that the new CEO is accountable to a board and so on. Parents get very frustrated when they hear that because they feel, at a corporate level, Children’s Health Ireland has let them and their children down. I can accept and understand that.

I welcome the fact four board members have stood down, as has the chair. Other members of the board need either to be stood down or to stand down, and they need to be replaced as quickly as possible if we are to have confidence. Although I am not sure how accurate this is, I saw media reports which suggested that there may have been some discussion about the responsibilities of the board being subsumed into the HSE board. I am not sure whether that is legally possible, and I do not know all of the circumstances around it. What I would say is that every option has to be on the table to ensure there is good governance and good management.

I will put another point to the Minister, and I say this sincerely and genuinely. A task force was set up in Children’s Health Ireland. Many parents at the time told me they could not sign up to the task force because they did not have confidence in the same people in Children’s Health Ireland who had let them down so badly and who were responsible for all of those failures. Again, I can understand that from those parents. However, we have a situation now where an expert panel is going to be established to look at and evaluate each individual case. I welcome that because it is necessary. I want every child to have their case reviewed. However, it has to be at arm’s length from Children’s Health Ireland. The Minister has said that will be the case. Obviously, I will wait to see the terms of reference and the criteria involved when they are published.

We have to make sure that in everything we do now, families and children are put first, which, to be frank, they have not been to date. Families contacted me yesterday regarding the phone line. While some of them were grateful that at least there was a hotline, in reality, to use their words, they felt the people on the other end, through no fault of their own, could not provide them with answers and were using what the families thought were responses to frequently asked questions. They felt let down by that and this compounds the anger and frustration those families have. Let us put children and families first in everything we now do to establish the facts and make sure these children get the care they need.

I want to use my remaining time to deal with the other issue that came into the public domain regarding the potential manipulation of public waiting lists. Again, I have a high regard for consultants, who do a fantastic job. I am on record as supporting the Government in putting in place a public-only contract. It is a very important transition that we need to make to remove private healthcare from public hospitals. I very publicly welcomed that at the time because it was the responsible thing to do. I called for it and I want to see it in our public hospitals. However, I have been concerned for some time about the use of public money for insourcing in hospitals to deal with waiting lists. It is necessary and we know we need waiting list initiatives because waiting times are too high. However, I have been raising concerns about the potential for conflicts of interest, perverse incentives and, I would argue, issues of productivity within the public system.

We have to ask genuine questions about what work some consultants are doing from Monday to Friday when they are paid from Monday to Friday to carry out public procedures. We need to contrast that with the so-called blitzes and private clinics they are organising and running, while charging €200 for each client they see and making very handsome amounts of money. I know this is a contention and that the outcome of the investigation, internal as it was, has not been published. It was a mistake not only not to publish the result of that investigation but not to forward it as well. I refer to the investigation into the practice of a consultant.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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It is not finished yet.

David Cullinane (Waterford, Sinn Fein)
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No, there was an internal one that the story this broke in the media. I assume it is the same for the Minister, which is unacceptable. I know further investigations into this matter are taking place.

I am making the point that we have a system in this State where someone goes to a GP, is referred to a consultant and is then on that consultant’s list. There are bespoke options in some hospitals and some now operate what is called a centralised referral system. However, it was not the case in every situation and it does not currently seem to be the case in every situation. As I said, there is the potential for a perverse incentive for a consultant to manipulate public waiting lists and delay people getting access to care. In this case, the allegation is that it was with children - which makes it all the worse, in my view - in order to delay care and not allow other surgeons and healthcare practitioners to treat those children, but simply to treat them on a Saturday or Sunday and make money out of it. I do not know how widespread that is but wherever it happens, it has to be rooted out.

My understanding is that the CEO of the National Treatment Purchase Fund is not responsible to any Oireachtas committee and is not an Accounting Officer. That is a mistake. There are many issues. A huge amount of public money is being spent by the National Treatment Purchase Fund and it has particular responsibilities in regard to setting nursing home fees. I accept it needs to be independent in coming to those conclusions and not being affected by political influence. However, when it comes to the huge amount of money that is spent, as a former member of the Committee of Public Accounts, the Minister will know how important it is to achieve transparency. There are major issues that need to be examined. I have spoken to the current head of the HSE and I said that, for me, there are issues in relation to perverse incentives, the productivity of consultants across the system and conflicts of interest. Again, while I know this is an allegation and a contention, if it is the case that, as reported, this person delayed care for children, then made an application through the hospital for funding from the National Treatment Purchase Fund to treat the same children and did not disclose he was going to be the surgeon carrying out those private procedures at €200 a pop, that is a major conflict of interest that was not managed. I am deeply concerned about that.

I have dealt with hundreds of parents in recent months. Earlier I checked and saw that in the couple of hours before I came to the House, I had received 14 emails from parents.

I simply could not do justice to all of them in relation to the accounts they gave to me of their experience but suffice to say that all of them feel hurt and let down. They felt they were not listened to. They felt they were still being failed. They will have to wait now. We do not know how long it will be before this expert panel is established but they feel very angry. I want to be part of helping to restore their trust but unless there is a voice for parents and a voice for advocate groups in whatever arrangements are now put in place, that trust will not be repaired. That is hugely problematic. We all, in particular those in government, have a lot to do to repair the damage and repair the trust, which, undoubtedly, needs to happen if parents are to have trust in CHI again.

Marie Sherlock (Dublin Central, Labour)
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I welcome that we are having statements on this this evening. Although I, for one, would much rather we were talking about all the many other issues in the health service, such as the huge inequalities we see, particularly in the primary care system, we are back again talking about CHI this evening.

When we look at the revelations at the weekend on top of the report last week, we are seeing anxiety levels among parents go through the roof in terms of their questions about trust and confidence in the individual hospitals that make up CHI. From talking to doctors and nurses in CHI, I am struck by how morale is on the floor. This drip feed of revelations is so damaging to the excellent work that so many of them are providing day in, day out.

If I counted correctly, we have had four externally-commissioned reviews over only three years in CHI, each looking at a specific aspect of care in CHI. Of course, three are published and we are waiting for the Nayagam report. Two have, I suppose, what I might call systemic recommendations - both the Boston hospital review and HIQA's. Obviously, the Mr. Simon Thomas report was more confined to pelvic osteotomies but between Boston hospital and HIQA, we have had 59 recommendations, if I counted them correctly. Many of these recommendations arise from the same conclusion that there were systemic cultural, clinical and management failures and point to the same fundamental reforms. Of course, some of these recommendations date back to 2023 and we are still not in any way clear that those reforms are fully under way.

When we looked on Sunday at the internal inquiry in CHI and its stunning revelations, on top of the appalling allegations that children were not cared for in a timely manner and that there was a possible abuse of the National Treatment Purchase Fund, NTPF, it is incredible that it seems the Department of Health, the Minister herself and the HSE appear to have been kept in the dark. It is a reflection of the level of dysfunction at the top of CHI that that was not communicated to the Minister and the Ministers of State, in particular because of this semi-permanent state of crisis that CHI finds itself in. I very much welcome the moves the Minister made over the weekend. I welcome the appointment of the HSE board members and the enhanced operational oversight by the HSE.

We have also been looking at the reports of the legal advice the Minister's predecessor received last year with regard to that substantive and fundamental change of governance at the top of CHI. To be clear, we in the Labour Party will not be found wanting if legislation is brought to this House in terms of ultimately bringing the board of CHI under the full operational oversight of the HSE because to have a situation, as we have had over recent weeks, where the HSE is effectively accounting for the failures of an organisation which it does not have full operational control over and oversight of is simply daft. It is telling that the HSE had to come in particularly in terms of the briefing on Friday on the set-up of the external review and that it is the HSE, as opposed to CHI, that is very much, along with the Department of Health, leading on this.

I want to make clear, I suppose, from many of my conversations on the ground that I understand the new CEO of CHI is somebody who people speak very highly of. That is very welcome but I am not sure that, in itself, enough anymore in terms of the governance of CHI.

On the Simon Thomas report, I have a number of questions. Why is the review only going back to 2010? As I understand it, it is because those children born in that year are currently ageing out of the paediatric children's hospital services, but there are children older than that, aged 17, 18 and slightly older, whose parents have also raised concerns with me about whether those children were caught up in the unnecessary pelvic osteotomy procedures. If I heard correctly, the CEO of the HSE, whom I have great time for, stated on Sunday that it was believed there was a situation with the clinical audits and that there was some reference made to 2010 but I understand from talking to other surgeons that the practice of clinical audits goes way back and is a key part of all surgical training so that it not having been embedded into the oversight procedures within CHI is, in itself, stark.

While the offer from the HSE with regard to the external review is confined to patients who have undergone pelvic osteotomies, and the protected disclosure, of course, related specifically to that, I have to ask the Minister whether she is confident that there were not other procedures conducted by those same surgeons that may have also been deemed unnecessary or perhaps did not meet the internationals standards for clinical indication because there is an air of distrust now with regard to all the procedures that have been undergone.

The review that was published on Friday related to children aged seven and under who had the pelvic osteotomy operations but I had a family contact me whose daughter was 13 years of age and underwent a similar procedure. At the time, the family felt the decision was quite rushed but, nonetheless, they were in the hands of the surgeons. I suppose my ask is that in terms of the opening up of the external review, it would be opened up to those children older than seven years of age.

One of my final questions relates to the change with regard to this new single peer-led review of a team of all surgical decision-making. Is that only for pelvic osteotomies or for all surgical procedures within CHI? That is a critical question.

Some weeks ago, I raised the issue of the status of current activity within CHI. Have surgeons been referred to the Medical Council? While these reviews are ongoing, has activity been temporarily suspended or reduced? I understand that is not the case. There is also a situation where we know that there are approximately 220 children currently awaiting orthopaedic procedures. Those families are obviously deeply worried that there will be any sort of reduction in activity and we need to provide assurances to them.

On the steps being taken now and the letters being set out, the question has to be asked that with all that has gone on, how could CHI be so tone deaf as to insert in its letter that only one parent attends? Perhaps the Minister might be clarify that because the parents who have contacted me stated that they feel broken and that their confidence has been shattered because of the uncertainty of whether they have put their child through an unnecessary procedure.

I will refer to a woman who contacted my colleague Deputy Mark Wall today. Her three children had undergone pelvic osteotomy. She secured a review with the surgeon two weeks ago. An X-ray was taken and this was followed up by a meeting with the consultant. She asked the questions and the surgeon told her that he had done her children a favour for their future. She is not sure who to believe any more. Who precisely will provide the follow-up care for every child who has undergone pelvic osteotomy that has now been committed to? Will it be the surgeon who undertook the procedure or somebody different?

I am conscious I have only a few seconds left but there are now serious questions about the NTPF. I refer to the allegations made on Sunday. We would like that report to be published as soon as possible. There are serious questions about the NTPF and an audit of its processes needs to be undertaken.

Erin McGreehan (Louth, Fianna Fail)
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I welcome the opportunity to speak on this highly concerning matter, which has rocked many families across the country. The lack of any sort of organisation or accountability within CHI is a grave matter. This has rocked every parent and devastated the affected families again. It shakes public trust in our healthcare system to its foundations. What is happening in Children's Health Ireland at the minute can only be described as an extreme crisis. What was supposed to be a beacon of excellence for paediatric care is mired in dysfunction, delay and disillusionment resulting from a long list of mistakes. The further resignations from the board today are symptomatic of this.

The results of the recent audit into paediatric hip surgeries conducted by Children's Health Ireland and the National Orthopaedic Hospital Cappagh have exposed systematic failures. The findings of the audit are stark and beyond alarming. The majority of the pelvic osteotomy procedures carried out in CHI at Temple Street, 60%, and at the National Orthopaedic Hospital Cappagh, 79%, that were looked at did not meet the clinical indication of the agreed standard applied for the audit. The majority procedure looked at in Crumlin, 98%, did meet that clinical indication. The report further states that, while there is worldwide variability between surgeons, the variance identified in the audit cannot be accounted for by measurement error or observer variability alone. Surgeries being identified as having been carried out without sufficient clinical justification means that children underwent operations that were not only inappropriate, but potentially harmful.

This issue goes beyond medical error; it is an ethical failure and absolutely disgusting. If children undergo surgery that is not necessary, it is not a clinical misstep but an assault on their wee person, their health and their trust. To perform a procedure without just cause is an unconscionable violation. Where do families turn now that trust is gone? How can they place their children into the care of the same hospitals now? The health service has a lot of work to do. I hope this can be rectified but the appalling allegations will make it difficult.

I have spoken to the mothers of children who have had this surgery. They feel lost in bureaucracy and need to be given answers quickly and efficiently. There are children who are learning to walk again, who were discharged in agony and who were given incredibly strong drugs with no follow-up. It is incredibly upsetting. It is unbearable for me to think of the size of those wee people affected by it. Transparency, openness, flexibility and support for those families are necessary. A mother contacted me. She had immediately lost confidence because, when she called the phone line on Friday, the person who answered did not know the answers and the mother had to spell out "Cappagh" for the individual taking the notes. It does not instil confidence.

The Government must take immediate steps to address the shortcomings revealed in this audit. I welcome the clear plan outlined by the Minister. I hope there will be co-operation with her and with the follow-up. Transparency is needed, the families need answers and the children need proper trauma-informed follow-up care. If they do not wish to go back to the hospital where they were treated, they should be given financial support to travel for the follow-up care they require. I would find it very hard to place my child in the care of a hospital that had potentially butchered them.

I will highlight another point that I hope will be investigated. It has been touched on by speakers from across the House this evening. We need to check if there was a correlation between patients having private health insurance and having unnecessary surgeries. The families I have spoken to had private health insurance. They feel sick because they tried to do their best by their families in getting health insurance to get better care but may have been taken advantage of by a hospital seeking a quick buck.

The governance issues must be worked on in an incredibly efficient manner. Parents and children need to know everything about those children's time under the care of these hospitals. Care, support and alternative medical follow-up must be given. Accountability for all the wrongdoing must come without haste. Trust must be reinstated. I wish the Minister the very best of luck because she has hard work to do. The Government did not do this but it is the Government's job to clean it up.

Martin Daly (Roscommon-Galway, Fianna Fail)
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It is with significant regret that I have to speak today. I am a member of the medical profession. I am not an orthopaedic specialist but I am a doctor of nearly 40 years' standing. The Thomas audit of the management of developmental dysplasia of hips in children in CHI at Temple Street and Crumlin and the National Orthopaedic Hospital Cappagh is deeply disappointing and unsettling, most especially as it follows on from the use of non-medical grade springs in spinal surgery in CHI. My thoughts are primarily with the children whom Mr. Simon Thomas states clearly should not have been operated upon and with their families. The trust patients and families place in doctors is the bedrock of our profession. That trust has been ruptured by some surgeons in the hospitals at Temple Street and Cappagh and these must now explain their actions.

These were not marginal decisions. Another hospital in the same group of hospitals in the same small city - the hospital at Crumlin - followed a starkly different standard of practice and is vindicated in the Thomas audit. The Thomas audit into the management of DDH in children has brought clarity within the limitations of its terms of reference. However, it raises many new questions about governance, ethics, consent, clinical judgment and decision making. This is more than clinical misjudgment. It shows some surgeons strayed far from evidence-based practice and ignored internationally accepted protocols. While Mr. Thomas notes that, while some variance in DDH management could be expected, the variance of pelvic osteotomy rates across CHI at Temple Street, CHI at Crumlin and Cappagh hospital, which is in the order of 60% to 80%, is inexplicable. No plausible explanation was offered.

I acknowledge the Minister's swift response to the official audit report and welcome the appointment of two HSE board members to the board of CHI, the increased operational oversight of CHI by way of an enhanced service-level agreement, the cross-hospital interdepartmental peer review group for consideration of any further surgeries and the commitment by the Minister and the Taoiseach to establish an independent external review process. However, broader questions remain regarding CHI's culture and governance and its relationship with the HSE. This is especially urgent in light of reports alleging unethical and irregular referral practices by a consultant in an internal CHI report and the alleged toxic work environment for junior staff. The non-action by management in response to that report is simply incredible but our immediate concern must be the care of affected children and families. Proper follow-up must be carried out to skeletal maturity. This is standard best practice that was lacking at Temple Street and Cappagh. Every case back to 2010 must now be independently reviewed. This is a major undertaking but it is essential. We must ensure this does not further delay care for children awaiting surgery.

It is incumbent upon the Government and this House to tease out the systemic failures this DDH debacle has revealed. The key issues are managerial culture and governance, clinical culture and governance and the process of clinical decision making at Temple Street and Cappagh. In many hospitals, critical robust collegial peer review of cases is standard before any treatments are carried out. We need to understand why some surgeons deviated so sharply from accepted practice. Mr. Thomas suggests a small subgroup of surgeons carried out a significant number of pelvic osteotomy procedures and an unusual number of bilateral pelvic osteotomy procedures in particular. These must prompt professional reflection, remediation and accountability to the appropriate bodies. Informed consent must also be addressed. Mr. Thomas details what adequate consent looks like and highlights poor record keeping, underlining the urgent need for hospital digitalisation. The health committee should explore these matters to clarify the management culture and governance of CHI and Cappagh hospital and the practices of individual surgeons.

As I have said, it gives me no pleasure to make this statement but we are obliged to act. The failures highlighted in the report by Mr. Simon Thomas on the apparent governance vacuum at Temple Street and Cappagh hospitals serve no one well, not the children, not their families, not the medical profession, and certainly not the State. We must learn from those mistakes.

Pearse Doherty (Donegal, Sinn Fein)
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When we read the report words kind of fail us. We have heard words over the last number of days such as "shocked" and "disgraceful" from parents who are dealing with the anger and the emotion. As my party colleague, Deputy Mary Lou McDonald, mentioned earlier, one parent felt they had let their child down. This is an emotion expressed by many of the parents I have spoken to. It is the wrong emotion because it was not they who let their child down; it was the State, it was the system, it was CHI, it was Temple Street and Cappagh hospitals, it was governance and, I would argue, it was the Government. We are used to hearing about scandals and about reports but when we are talking about numbers, we must remember that 80% of the operations at Cappagh hospital were not necessary and 60% in Temple Street hospital, and every single one of those involved a child. We are talking about hundreds of little girls and little boys who went into an operating theatre, who had serious and invasive surgery carried out on their hips and who are learning how to walk again. A bit of their childhood was stolen from them. We are not talking about one, two or three: we are talking about hundreds and hundreds of children. How did this go on not for one year or two years but likely for quite a number of years? We know of parents who went for second opinions and the consultants told them they did not need the operation as the child did not even have the condition and said words, which were relayed back to me, such as, "We are alarmed at what is happening in Dublin". How was none of this noticed? Over the years my colleagues on these benches have been raising different issues in relation to CHI and governance issues so why did the Government not take a deep dive into CHI and actually looked at what was going on? When the leaked report came out, I stood here two months ago to say to the Government to get ahead of this. This is a scandal the likes of which we have never seen. Even today there are parents in my constituency of Donegal as well as right throughout the State who do not know when they will have that independent analysis assessment so they may know whether or not their child needed that operation. How is it that over those two months one parent sent 30 emails with no response, only to get a response when they threatened legal action? Does the Minister know the response the parent received last week? It was that they would be in touch with the parent in the coming months. This is a disgrace. It is a disgrace of governance, it is a failure of practitioners and it is a failure of the Government to get ahead of this issue and to deal with it when it was brought to its attention quite a number of months ago.

Pádraig Rice (Cork South-Central, Social Democrats)
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It is really hard to know where to start when it comes to CHI. The report that was published is shocking, disturbing and deeply upsetting for families across the country. It confirms what we have known and what we have said in the House for some time, that unnecessary surgeries took place on children. We know what happened and now we need to know why that happened.

I have a list of questions as long as my arm that need to be answered. As a new TD, I do not believe this format of long statements and posing questions without getting direct answers works. I ask the Ceann Comhairle to think about that in the context of the functioning of the House. It would be far more beneficial for us and for the families affected if we could pose our questions and get direct answers from the Minister, and have that time for the back and forth direct engagement. There are lots of serious questions that have been raised over the last hour or so and we have not had a chance to hear any answers from the Minister. I ask this in terms of the functioning of the House so that we do our job better for the families and get direct answers to our questions.

I have ten questions I would like the Minister, Deputy Carroll MacNeill, to answer in her reply. How long will the external review take? Does the Minister know how far back this issue goes? We know that letters have been dated back to 2010 but does this go back further? Are we looking at something that goes back to the early 2000s? Reference was made to a published academic paper but what is that paper based on? Is it based on surgeries that happened before that? We need to know how deep this issue runs. Will there be further investigation to determine how this scandal arose and persisted for so long without anyone in CHI or Cappagh hospital being aware of it? Will the Minister conduct a review of clinical directors? Could children under the care of CHI surgeons in other hospitals be affected? We know that they worked in other hospitals such University Hospital Galway. Crucially, and as referenced by others, has financial incentive been completely ruled out as a motivating factor here? Have any doctors been placed on leave? Are any doctors contesting the findings of this report? Are there any legal proceedings against CHI as result of the scandal? Does the Minister trust CHI to take on the running of the national children's hospital? These are just ten of the many questions that I, others and parents have. They are questions we would like to get answers to. As we go through this report and delve through it, there will be more questions that need answers.

To that end, in my capacity as the chair of the Oireachtas Joint Committee on Health, I have invited CHI to come before the committee. I and the other members would expect that to happen quickly and not be delayed. Hopefully, we will have that engagement with it sooner rather than later because we need to get answers to these questions.

The report raises really serious concerns around the novel procedure and the serious failings around informed consent and lack of clinical follow up, which was another key issue. What we need to see now is that independent panel established quickly. It is key that there would be independence there for families. They are quite worried about the lack of independence. This needs to be put in place. The report, which I read through more than once, trying to get my head around it, highlights many issues: poor record keeping; the different criteria applying in different hospitals, which is deeply worrying; the lack of oversight; and indications of children having complications. There are many issues that need to be addressed urgently.

I suggest to the Minister that in future with these kinds of issues, and particularly those of a real technical and medical nature like this, it would be worthwhile publishing at the same time an easy-to-understand guide for families and having a version that people could understand. In reading through this report, I struggled to understand this as someone who is not a medic. It would be worthwhile having something that is easier to understand for families and parents issued at the same time.

I commend the whistleblower on raising these concerns, and also the parents and families who have been raising the issues. Some of them feel they have not been heard. Over many years they have been raising concerns around CHI and its processes and have felt stonewalled and unheard. That culture needs to change. We know there are serious issues with culture. The HIQA report talks about the issues around culture, governance, the lack of communication, and the lack of oversight. There are many issues that need to be addressed.

These are not the only serious concerns that CHI needs to address. There is also the use of unauthorised springs, and more recently the reports at the weekend around the National Treatment Purchase Fund. I would like to see that published. I would like to know whether there has been a referral to An Garda Síochána. I would like to know also whether there has been a referral to the Medical Council and what actions have taken place on foot of that. The report is deeply disturbing about patients being cherry picked and put on private lists in order to make more money. The lack of oversight there and the lack of awareness by the HSE and the Department of Health in that regard is deeply worrying. With the National Treatment Purchase Fund, we are talking about very large sums of money around €240 million. We must ensure this money is being spent correctly. These reports are deeply worrying.

This morning my party's deputy leader raised the Social Democrat's deep concerns about the situation of clinical directors. These are consultants who have been given the task of supervising their colleagues, and who receive an additional allowance for that work. This was introduced in 2008 to ensure consultants were adhering to their contracts. In 2017 "Prime Time Investigates" revealed that consultants were gaming the system in many ways. At the time, the Social Democrats raised serious concerns about the role of clinical directors. The latest revelation at CHI shows that clinical oversight is still issue. We want to know how these processes were happening under the noses of highly-paid clinical directors. We would like to see that system reviewed. I would like to know the number of clinical directors employed with the health service, where they are based, the number of consultants they are overseeing, and the reporting arrangements in place.

A lot of this comes back to clinical governance and that needs to be looked at.

I welcome the Minister's interventions over the weekend, particularly the swift action she took on the appointments to the board. That work needs to be commended. From the Social Democrats' perspective, we want answers, not heads. We need to know what happened at CHI. We also have fundamental questions about the purpose of CHI, whether it is needed and what the plan for it is going forward. This is an HSE-funded but not HSE-controlled organisation and there are serious issues there. There are issues about building in these additional layers that we might not need in our health service and whether the HSE can directly manage these hospitals. The national children's hospital is a €2.2-billion hospital, as the Minister knows. We need to get this right. We need to spend time and carefully consider it and I ask for that to be part of her consideration.

In terms of the bigger picture, there seems to be a lack of controls and accountability. We in the Social Democrats have long argued that the mix of public and private together in an uncontrolled system without accountability is toxic for our health service. This is why we fundamentally believe in the delivery of universal healthcare through Sláintecare. That needs to be accelerated, however. We are now a number of years into a ten-year plan and we do not believe it is happening quickly enough. Until we deliver universal healthcare that is free at the point of use in the community and based on need and not ability to pay, these issues will arise again and again, and we will face future scandals. While this is looking at one particular issue in one particular section in one particular hospital, the issues are systematic and will not be addressed until we rebuild and reform our healthcare services and deliver the type of universal, single-tier and high-quality services that are enjoyed by people throughout Europe. As an Oireachtas, we need to collectively get behind the agreed Sláintecare reform plans and accelerate those because the children of Ireland deserve better than what we are seeing in these reports and scandal after scandal.

Peter Roche (Galway East, Fine Gael)
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The Minister has inherited quite a difficult situation. I do not doubt her response, her hands-on approach and the swift action that she has taken. I read in a report that she means business, and rightly so.

It is shameful that we have to be talking about this kind of a calamity happening in modern-day medicine. It is hard to believe. Sitting at home listening to the news reports, I found myself saying "Not again." It beggars belief that this is happening in this day and age. However, we are where we are. I thank the whistleblower. Great credit has to be given to the person who felt the need to highlight this issue. We do not want to hear about it, but it is a reality. The fact that it is a reality means it needs to be dealt with, and it has been entrusted in the good Minister to do that. When we take our most cherished children to the hospital for care, we expect that they are in a safe place. We certainly expect that they will be cared for in the trust of the professionals caring for them, confident in the knowledge that every decision is grounded in evidence, compassion and accountability.

The findings of the CHI audit raise deep and troubling questions about whether that trust was upheld. We have also heard that nearly all surgeries reviewed in Crumlin hospital were found to have been appropriately selected for surgery based on current international standards, which is good. At Temple Street and Cappagh, however, the audit raised serious "concerns" about decision-making, where a significant number of procedures were carried out without meeting the acceptable clinical criteria, including surgeries on children with a stable hip and no prior treatment for DDH. Families are rightly being contacted on this issue because fundamental questions have been raised. The questions we all ask are: how did this happen?; why was it allowed to happen?; where were the checks and the balances?: why was the governance so weak? and, most importantly, how can we ensure that there is no repeat of it across any sector? There is no question of clinical variation. As the report makes clear, the scale of unjustified procedures cannot be explained by differences in judgment alone.

I welcome that these patients are being recalled for review and that the HSE is establishing, under the Minister's watch, an independent expert panel. That is really welcome and reassures me that we are responding to the crisis. This needs to be done not only for the families affected, but because public confidence in our health service needs to be restored. Most importantly, all future DDH surgery decisions will be consistent, evidence-based and focused solely on the best interest of the child. This is where governance must deliver, not as an abstract policy, but in real clinical decisions with real positives for real people. When governance fails, the patient pays the price. It must not happen again. We owe these families a lot of honesty, respect and, of course, accountability. As a member of the health committee, Deputy Rice, our Chair, has referred to the fact that we will be hearing lots more about this. It behoves us to respond in a professional and dignified way in terms of the way that we deal with these discussions.

There have been a lot of contributions. Many people and Members of this House have suggested that they know some of these families. I am no different; I know one family. That brings the whole thing closer to home. I commend the Minister on her swift action. We look forward to the findings of the independent review that will establish whether the surgeries carried out were necessary. That is most welcome. As I said earlier, we need to give reassurance to the general public.

Louise O'Reilly (Dublin Fingal West, Sinn Fein)
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Parents are very worried tonight. They are worried that their child might have had an unnecessary operation. They look to the Government for answers but all they seem to get is an endless commentary. I heard the Minister's commentator-in-chief, her boss, the Tánaiste on the news earlier. He was outraged. He described, in detail, the long lists of all the people whom he thinks should have been paying attention, conveniently forgetting his own role as a former Minister for Health and the role of his own Government in yet another scandal. There was the scoliosis scandal, the CervicalCheck scandal and the children's hospital overrun scandal - the list goes on and on. The questions that parents are asking are fairly simple: could this have been avoided?

The consultant identified by the 2021 internal investigation into CHI, who, it is alleged, was enriching himself or herself at the expense of sick children, may be a pretty poor example of this behaviour but the current system subsidises the failing of the public sector by funding the private sector. The Minister's colleague Deputy McGreehan said earlier that the parents with private health insurance wanted to do their best for their children and get the best care and that is why they have private health insurance. Imagine saying that. That is from one of the Minister's colleagues. With private health insurance, people should get themselves as far away from the public system controlled by the Government as they possibly can. Do right by your kids, and get private health insurance; that is some message for parents. I do not know what the Government is saying to parents who cannot afford private health insurance. I do not know what the message is to them this evening.

The Government has created a system whereby there are two tiers. Mechanisms such as the National Treatment Purchase Fund create perverse incentives. It has been seven years since I met with the then Minister for Health, now Tánaiste.

8 o’clock

I outlined to him a Sinn Féin proposal. It works in other jurisdictions and we had modified it for this jurisdiction. We called it Comhliosta. It was a single, integrated waiting list management system that would remove those perverse incentives and ensure the health service was working at maximum capacity so as to enable a person waiting to get the next best place for them. It would eliminate, to a huge extent, the perverse incentives that, apparently, have been highlighted now. Those perverse incentives have served to let children down.

In my final few seconds, I will say that parents will have a voice in this Chamber because we will ensure they have a voice here.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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We are all parents. I thank the Deputy so much-----

Louise O'Reilly (Dublin Fingal West, Sinn Fein)
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I thank the Minister for heckling me.

Louise O'Reilly (Dublin Fingal West, Sinn Fein)
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I thank the Minister. This is my time.

Verona Murphy (Wexford, Independent)
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Deputy, your time is up. I call Deputy Coppinger.

Ruth Coppinger (Dublin West, Solidarity)
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We have seen it all at this stage. We have had unnecessary hip operations, unlicensed springs implanted into children, defective technology being a fixture in operations and we have had Wi-Fi issues. There is something new every week. Now, we have a doctor who, allegedly, referred public patients to their private clinic at the weekend and was paid money by the National Treatment Purchase Fund. This fund is meant to be used to expedite the most needy people first but these were not necessarily the children with the greatest need. The Minister's backbenchers keep thanking her, but she must listen to parents. We just heard an apology given to parents in the previous session. We all know we are going to be back here apologising to parents and the Minister is just stringing this out for as long as possible.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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No, I am not-----

Ruth Coppinger (Dublin West, Solidarity)
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I do not have time to make all the points I wanted regarding the research. I just want to say what the parents believe needs to be done at this stage. The HSE was proposing a two-stage review, by the CHI first and then by outsiders. That has been completely rejected. They are putting forward the idea of a partial ratified independent scrutiny mechanism, PRISM, as it is called, where the parents themselves would have a say in what happens and scrutiny over the whole situation. It is incredible how knowledgeable the parents are. I am sure the Minister knows this because she has met them. There must be a full and comprehensive review. Every parent and child should be entitled to a second opinion and not have to wait six months as is currently being proposed. We also need a full public inquiry into CHI. Every case should be audited and not just those chosen. We all know this is just being strung out. The board needs to go. There is no way it can move forward, in terms of CHI, into a new system. It has been absolutely ruled out.

Séamus Healy (Tipperary South, Independent)
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As someone who worked for more than 21 years as a hospital administrator in a general hospital, I am lost for words to describe the mayhem which is Children's Health Ireland. The word "bewilderment" comes to mind. It is certainly shocking. The first principle of the provision of a health service is that the patient comes first. We might say that is old-fashioned but it is still 100% true. There has been a fundamental breach of trust here, which has not only not put the patient first but that has harmed patients, in this case children.

A series of reviews, reports, audits and investigations, including those undertaken by HIQA, the HSE and others, paint a picture of toxic, chaotic systemic failure at all levels. It has been at the level of governance, clinical oversight, procedures, breaches of procedures, breaches of guidelines and breaches of protocol. Putting children through the pain and suffering of surgery for developmental dysplasia of the hip that may not have been necessary in 70% of cases is simply unconscionable. The parents of these children are devastated and they have no confidence in the review process being proposed. They are rightly asking for a public inquiry and an independent clinical review by independent international paediatric orthopaedic surgeons. They are also demanding to be centrally involved in drawing up the terms of reference. The governance of the hospital must also be addressed and I believe the board must be stood down and the operation, control and governance of the hospital transferred to the HSE, which currently funds the hospital.

Catherine Connolly (Galway West, Independent)
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This is our second report and we are waiting on a third one. In this second report, we are told the percentages of the pelvic procedures carried out not reaching the criteria are so high that a further inquiry is mandated. The Minister is doing this now in respect of a look back at all of the patients, and I welcome it. We then look at what the percentages were because we cannot repeat them often enough. At CHI at Temple Street, 60% did not meet the clinical indication requirement, while at Cappagh 79% did not meet the clinical indication requirement. Those high percentages of unnecessary operations were carried out.

I welcome the changes the Minister is making. I wish to zoom in, however, on the board of CHI. I recognise the people there are serving with no remuneration. We need to look at this whole model. I believe hospitals should be run by the HSE. That CHI board has been there for a long time. It was put on a statutory footing in 2019. There has been a major turnover of directors. We had them before us at the Committee of Public Accounts on Thursday. I take a lot of the blame myself in regard to our inability to ask questions in a set space of time, but I was singularly unimpressed with what came before us at the committee. The Minister might look at it. We had a new CEO who knew nothing about anything except to tell us the settlement in relation to the previous CEO was confidential. That CEO had a new name and same salary and nothing else. That CHI board also presided over €250,000 it failed to collect from private insurance. Its representatives were before us without a chairperson or a single member of the board to account for anything. They referred to there being a report every year or an internal review carried out by external people. They could not tell us anything about that, however, because that was simply for them to learn. The Minister seems to have got one of those reports lately, but one is carried out every year, they tell us in the financial statements, to reassure them regarding governance. I received no assurance.

Paul Murphy (Dublin South West, Solidarity)
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I have several questions. Why are the surgeons who performed hundreds of unnecessary surgeries on children still operating? Surgeon B could go into Temple Street tomorrow and do an osteotomy. Those surgeons are not being prevented from doing that. There is a lot of talk about rebuilding trust and so on, but all that seems very previous to me when, literally, the surgeons who are responsible are still operating in Temple Street and Cappagh. I think they should be suspended, but, at the very least, they should be suspended from carrying out osteotomies.

Is there any ongoing investigation into motive? My understanding is that if a child had private health insurance a surgeon would get around €1,500 for doing one side and another €750 on top for doing the other side. That is a significant incentive that may well have distorted the best health outcome for children and shows the poisonous role of private money in a public health system.

Is the Minister confident that CHI agrees with her when she says there is going to be a full review of every osteotomy done to see whether the operations were needed? I do not mean just to see that there were no complications but whether those children needed those operations. The parents do not need to request that, although, of course, they will need to consent to it. It should, however, be across the board. The Minister might check to see that CHI has the same understanding of the situation as she does.

Why are children from earlier than 2010 being excluded? Is it because they are no longer children?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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They can be included later.

Paul Murphy (Dublin South West, Solidarity)
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What is mentioned here at the moment in the CHI press statement, for example, is that all the operations are being studied from 2010 in Temple Street. We know these novel osteotomies started in 2002. It does not seem to me there is any good reason to leave them out. The argument is they have reached skeletal maturity.

They still deserve to know if they were wrongly operated on. That may have implications for their health into the future.

Colm Burke (Cork North-Central, Fine Gael)
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I thank the Minister for coming to the House to deal with this issue. This is a really difficult time for children but, in particular, for parents because children place their trust in their parents. The parents in this case placed their trust in the consultants and took their advice in coming to a decision about the best way of managing the medical care required.

Simon Thomas, who has been with the British Royal Hospital since 2007, carried out the review of operations performed in Crumlin, Temple Street and Cappagh. He found that Temple Street and Cappagh were doing something totally different from Crumlin. Crumlin seemed to have been doing far fewer operations, was not involved to the same extent and was following all the proper procedures in coming to decisions before performing these operations. The audit was carried out on pelvic osteotomy between January 2021 and December 2023. Paragraph 2.3 of the report states:

In many of the TSH [Temple Street] and NOHC [Cappagh] cases sampled, there was no record of closed or open hip reduction after delayed diagnosis, no record of either hip ever having been dislocated and often no history of treatment soon after birth by splint or brace for hip instability.

However, based on the surveys carried out, the evidence for the need for these surgeries did not appear to be there. It is accepted here in this House that the vast majority of consultants, junior doctors, nurses, care assistants and all the people who work in hospitals want to put their best foot forward and look after patients in the best possible way. The difficulty with this is the lack of trust that has been created as a result of what happened in this instance. It will take a huge amount of time and effort to build that trust back up. As a result, it is important that we do everything possible to make sure that there is full disclosure and that the families whose children have gone through unnecessary operations are given the necessary support.

We should have learned from history. A number of years ago, a consultant was doing unnecessary hysterectomies. That was identified in the past 15 years. We also had the whole issue with symphysiotomy, about which one person said, "He was sawing me in half." That was a grotesque way to carry out a medical procedure. It was in place of doing Caesarean sections.

While I am talking about Caesarean sections and the need for checks and balances, this is what I do not understand. I had understood that in all of our hospitals, regardless of the area of medicine, whether it is orthopaedics, maternity or paediatrics, there are checks and balances. Reviews are carried out in hospitals on a regular basis. That does not appear to be so in this case because these procedures were being carried out since 2010.

On maternity, the figures for one hospital in Ireland for February show that 73.5% of deliveries for first-time mothers were by way of Caesarean section. I would question the need for 73.5% of women to have Caesarean sections. It raises questions as to whether we are now taking decisions in order to fast-track what needs to be done. We need to set up a proper system right across the board in all of our hospitals in all of the different areas of medicine to make sure that reviews are carried out on a regular basis - not every year but at least once in every five years. That is something we need to look at.

Brian Brennan (Wicklow-Wexford, Fine Gael)
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I welcome the report. It is imperative that there is no delay in the roll-out of the recommendations it contains. There are three key issues. The first is how we deal with parents. Since the more than 2,000 letters were sent out, I have spoken to many parents. Without exaggerating, I can say they simply have not slept. They are totally numb at the thought that their child was put through a procedure that simply was not necessary. Many in this House understand what it is like to hand their child over to a surgeon in a hospital. The word "trust" comes to mind. At the moment, the trust between the healthcare system and these parents has completely broken . I ask the Minister to bear this in mind. With the consultations with the parents, they simply should not be sent back to the hospitals that already dealt with their children. A support helpline is warmly welcomed. Equally important, it is essential - and this is where it was great to see the report fully published - for the parents to be fully updated. I call for parents or their representatives to be included in the full review process.

I welcome the action has been taken and that there will be independent clinical reviews of every case. I welcome that independent experts from outside Ireland will conduct a thorough examination to ascertain if the operations were necessary. I understand the nature of this inspection will be complicated and take time. Bearing this in mind, I request that this process gets the full support of the Department of Health and is carried out as quickly as possible. As previously mentioned, the stress of not knowing for parents is hard to understand.

We must ensure that the management oversight and procedures are in place to ensure this cannot happen again. What happened with the governance of CHI? As a parent, I was lucky enough to reject such a call for procedure on my son. The questions on the lips of every parent affected who reached out to me are why and how. I agree with the full review on the findings in a sober manner and allowing due process for all involved. However, if we do not answer these parents' questions, we are simply not doing our duty. Why would a surgeon suggest carrying out an unnecessary medical procedure on a child? CHI has simply failed us on this. Individuals must be made accountable. That is the crux of this report. They have to stand up and look at themselves in the mirror. It is simply inexcusable that this was allowed to happen in this century. I await the review arising from this report with huge personal interest. I am aware that the Government is not responsible for this, but we are fully and firmly responsible for how we respond.

Thomas Gould (Cork North-Central, Sinn Fein)
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I express my gratitude and the gratitude of everyone to the whistleblower who came forward with this information. Parents need answers. Children must come first in this whole process. There needs to be open transparency and accountability. Children must have the follow-up care they need. Some 80% of the hip surgeries in Cappagh and 60% of the hip surgeries in Temple Street were unnecessary. That is just unbelievable. It is unimaginable that this number of surgeries that were not needed were carried out on children. Every figure represents a child.

The Department was notified in May of last year and began the audit last summer.

It is nearly June and people still do not have answers. They still do not know if their children needed surgery or not. In Cork, there are 32 families waiting for answers.

Every person whose child has ever had hip surgery now has serious questions. It is unbelievable that this has happened. Time and again, this State failed the most vulnerable children, including thalidomide survivors, those with scoliosis, those from mother and baby homes and children with disabilities. We had a child outside Leinster House last week campaigning for the legal right to assessments of needs because our Government will not deliver what was promised. Every child, no matter what his or her age now, who could be or who was affected by these unnecessary operations or who does not know if the procedures they underwent were unnecessary must be included in the process and have his or her voice heard. Where was the oversight? Where were the checks and balances? How could this happen? There are hundreds of children. How could it happen? There are serious questions about private healthcare.

Something radical needs to be done. Every year or every second year, we have scandal after scandal. When will it stop? I know from personal experience what it is like to have a sick child. I know from personal experience what it is like to be failed. The vast majority of doctors and consultants do a brilliant job, but some of them do not.

Verona Murphy (Wexford, Independent)
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I thank the Deputy.

Thomas Gould (Cork North-Central, Sinn Fein)
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I remember talking to a doctor who failed my family.

Verona Murphy (Wexford, Independent)
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Thank you, Deputy.

Thomas Gould (Cork North-Central, Sinn Fein)
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They were more worried about being sued. I was worried about my child.

Verona Murphy (Wexford, Independent)
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Thank you, Deputy.

Thomas Gould (Cork North-Central, Sinn Fein)
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I get what these parents are going through. They need answers now.

Verona Murphy (Wexford, Independent)
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We move to the Independent Technical Group. I call Deputy O'Donoghue.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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Accountability is at the very heart of this. The Minister is new to her role. She has hit the ground running, and I appreciate that. However, what has happened in Cappagh and Temple Street hospitals is unforgivable. There has to be accountability. We can look at it and nod our heads all day long, but at least now we are going the right direction. There will be no more hiding for anyone.

My first speech in the Dáil was about the management in University Hospital Limerick, and it has finally changed. They have a big task ahead of them, but it has changed. I now have somebody who will answer a phone to me. I have a Minister who will answer a phone to me. I have management who will answer a phone to me, and they will listen when it comes to what is happening within the hospital system.

There are some fantastic consultants out there. There are fantastic people across the network of hospitals. Then, we get a minority who take advantage, but that goes back to management. It has to go back to management, and there has to be accountability. Some members of management have resigned now. It is not enough. We need to make sure there is accountability for what happened to those children and their parents.

One thing we should look into is the fact that it is criminal activity if operations that did not need to be carried out were carried out for the reward of money. If this was embezzlement on the part of a company, people would be looking at the money trail. Why not look at the money trail of this and go back to those consultants who took on those operations that did not need to happen? Did they do it for financial reward or did they do it as best practice for the children involved. This report will actually show that.

Michael Collins (Cork South-West, Independent Ireland Party)
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The people parents trust most in the world are the doctors and surgeons who are supposed to care for their children. This is one of the most atrocious breaches of trust that can be believed. Imagine that, without your knowledge, someone who is supposed to care for your child implanted a device inside them. That should never have been allowed to happen. Compounding that, we find out that operations that were not necessary have been carried out on young children.

Independent Ireland has a simple plan: put patients first, hold leaders accountable and make the health service safe and fair for all. Right now, the HSE is too big, too closed off and too untouchable. That is why we want to create a real watchdog, fully independent of the HSE, to monitor what hospitals are doing. If something is being covered up, we want criminal prosecutions to be possible as opposed to just an internal memo being sent. We believe in protecting whistleblowers. Nurses, doctors or staff who speak up should be safe, not punished.

In the postcode lottery, if people live outside a major city, they know how hard it can be to get proper care. That is why we called for more funding for small regional hospitals in order that people in rural Ireland will not be left behind. Our policy states that 45% of the population live outside cities; they deserve access to urgent and routine care 24-7 just like everyone else. The Government should clear the waiting lists. It is no secret that people are waiting months, even years, for procedures. That is not just frustrating; it is dangerous. We support using private hospitals, both in the Republic and Northern Ireland, to get people the care they need faster, which I have been doing for the past number of years with our Belfast or Blind service, which I and Deputy Danny Healy-Rae set up. I also have the hip operation service. We want to expand elective surgery centres to stop the endless cycle of cancellations and backlogs. We need to rebuild trust. When children are harmed, parents are left in the dark, no one is held responsible and trust is broken. We need every family affected by the hip surgery scandal to be given a clear explanation, a full medical review of their child and support if their child has been harmed in order to allow them to move forward.

Ken O'Flynn (Cork North-Central, Independent Ireland Party)
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To sit still while children are cut open without cause is not policy; it is barbarism masquerading as procedure. The nation watched in horror as more than 500 children, babies and toddlers were subjected to major hip surgeries without proper medical justification. This is not just clinical error; this is systemic betrayal and a violation of duty. The Department of Health and the HSE knew. They were warned by whistleblowers - we congratulate and thank the whistleblower today for that - but nonetheless, the HSE did nothing. The people the whistleblower went to did nothing. That is not just a failure; it is complicity.

Earlier, the Taoiseach spoke about world-class health services and mentioned the children's hospital. Let me give the Minister a real-world fact. Ireland pays out more in medical negligence claims per capita than almost any other EU country. More than €2.5 billion has been paid out already in this decade. That is more than any other health system the size of ours, and still there have been just a few resignations. There are no consequences and no accountability. When it comes to healthcare, it is quite obvious that Europe is moving forward while Ireland is moving backwards. We are the outlier of the EU in terms of cost, care and basic clinical responsibility. Let me be clear. This Government cannot be trusted to investigate itself. I welcome that there will be an independent investigation, but it must have statutory powers. There must be no redactions, no delays and no whitewashing.

Many people on the Fine Gael and Fianna Fáil benches have spoken about progress. When they say progress, I see failure. Where there are promises of reform, I see ruin. The one thing I have seen from this health service is that regardless of whether someone is a child, elderly or out there working, he or she cannot trust the health service any more. The health service in this country is sick.

Paul Lawless (Mayo, Aontú)
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The entire scandal with regard to CHI has been shambolic from the outset. We have more than 200 children waiting for spinal surgery. There are children waiting for scoliosis surgery who are in pain. Meanwhile, very young children had surgery needlessly. This is the legacy. We have children the State has failed to treat and failed in terms of their treatment. What happened is absolutely shocking. What we have learned from the CHI whistleblower is that there was greater emphasis on protecting the system and protecting CHI than there was in terms of transparency. That is the real shame in this entire saga. Indeed, this was like a hit-and-run. CHI knew it had done immense damage. It knew that it crashed and yet it proceeded without even sounding the alarm. We had to wait for a whistleblower. The action that CHI took, particularly when it drafted the letter and then failed to send it, was utterly deplorable.

This has been a betrayal of children and families. As one mother who called me asked, "Who am I to question the doctor?" That is the attitude. It is a sad reality, but we have learned that maybe we need to ask questions about this. We trust doctors and medical professionals. The saddest thing is that the parents who gave so much trust realise now that they were mistaken.

We have also been made aware through reports and allegations that there are missing X-rays and pre-op files for assessments, which will make the task of investigation particularly difficult. That needs to be investigated. If it is the case that files and X-rays have gone missing on purpose, I hope the full sanctions available to the Minister come down on those professionals.

There must be a broader and more comprehensive review. That is the very least the families deserve.

James Geoghegan (Dublin Bay South, Fine Gael)
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I thank the Minister and Ministers of State for attending, making themselves available, responding to the issues and outlining precisely the measures taken in response to some of the events over the past number of days.

Words matter and for a Deputy on the other side of the House to tell the public in the Dáil that they cannot trust the health system is inappropriate.

Mary Butler (Waterford, Fianna Fail)
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Hear, hear.

James Geoghegan (Dublin Bay South, Fine Gael)
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It undermines and belittles the tens of thousands of nurses, doctors, healthcare assistants and people who are engaging in the health system every single day. This is a very challenging time for CHI. The issues that have arisen are serious. This is a scary moment for parents who are affected and have children who have been affected. However, that does not support a statement that says the entire health system is not to be trusted. The Deputy should consider that remark because it is not fair or supported by evidence and should not be said in that sweeping way.

This is a serious issue. On Thursday, the current CEO appeared before the Committee of Public Accounts and acknowledged and apologised to those affected by the HIQA report. She acknowledged and apologised to those who were facing the distress of having received letters arising from the audit. She also apologised to and acknowledged the families - I believe there are 35 - who were affected by the Nayagam report.

It appears following the revelations in The Sunday Times that the new CEO, who was not the CEO when any of this happened, may have to issue apologies in the future regarding children who might not have received the services to which they are entitled, which the Minister and the CEO of the HSE have acknowledged and expressed with some alarm. It was against that background that I wrote to the Chair of the Committee of Public Accounts on Monday seeking to recall the chief executive of CHI to appear before the committee at the earliest possible opportunity. It is clear that serious matters of public concern were not disclosed during the appearance of CHI before the committee last Thursday. The Sunday Times reports that an internal investigation conducted by CHI in 2021 identified the misuse of the NTPF by a consultant, resulting in treatment delays of up to three years for children in need of urgent care. As we know, this investigation was not brought to the attention of the Department of Health, the Committee of Public Accounts or any other relevant Oireachtas committee. It has to be said that is a glaring failure in governance, transparency and accountability.

According to the report in The Sunday Times, patients were selected by the NTPF-funded clinics not based on clinical urgency or time spent waiting, but on non-transparent criteria. Meanwhile, other children with more urgent needs were left waiting. We do not know at this moment in time who those children were, but the parents of those children and the children themselves are also deserving of an apology and perhaps more, depending on what all of the subsequent reviews reveal.

Further accountability is needed in the immediate term on the part of the current CEO, who has to account for things that took place prior to her reign. That is notwithstanding the fact that the former CEO is still a strategic director in CHI, albeit the HIQA report made clear in its findings in respect of governance that there were no specific itemised challenges made against her. For the benefit of the Committee of Public Accounts, it would be beneficial helpful to have the current and former CEOs appear before it. That is something I will raise at Thursday's meeting.

Ruairí Ó Murchú (Louth, Sinn Fein)
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We are all thankful to the whistleblower. The report that 80% of surgeries at Cappagh and 60% at Temple Street were not necessary should be shocking but unfortunately it is not. The Minister spoke about toxic behaviours in CHI. We have a history of issues in our health service, such as Michael Neary, Michael Shine, symphysiotomy and much more. It is a requirement that we deal with governance and accountability and also have a system that is fit for purpose. This needs to be done as soon as possible. Arguments will be made that a lot of these pieces of work could have been done before now, but we are where we are. We also need to examine the care of children and parents who have been through hell.

I want to talk about a constituent of mine who has three children, two of whom have been operated on while the third is awaiting surgery. The children are aged five years, three years and 18 months. She has secured a review by a consultant in the North. The cost of this for the three children will be in excess of €700. She cannot afford that. The appointment is on 10 June, but she will be like many others. Bernard Gloster spoke on the radio on Sunday, saying that those who wanted a third party review could get one and it would be paid for by the HSE. What mechanism will deliver on that? It is a requirement, as it is only right that the State pay. This is a mother who is not entirely sure whether her third child needs the operation or whether her two older daughters needed the operations they had.

Another mother living in mid-Louth spoke to me about her child who was aged three when she was operated on in 2023. She now looks at the scars on her daughter and cries because she is worried that they are the marks of needless suffering. Hers was one of the families that received a letter earlier in the year telling her that her daughter was one of the children reviewed in the audit. She is now struggling to come to terms with what has happened and what is going to happen. She has asked for a mechanism for getting her daughter's medical records. She has also spoken about the fact that she has not found the helpline entirely helpful. She does not blame the people at the other end; they just do not have the information. She spoke on Newstalk about this. We need to provide this information. She does not know what percentage her daughter falls into. We need that information and follow-up.

I have mentioned one of my constituents who, luckily enough, went for a second opinion. His daughter is now doing gymnastics, something that might not have been the case. We need such cases to be included in a review-type process also.

Gillian Toole (Meath East, Independent)
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In this instance, I am not going to duplicate all of the statistics and summaries of the review to date that Members have discussed. I will approach this from the point of view of what may happen next and the human impact. There must be a compassionate approach to supporting the children and families through the review process without sterile communications and an impersonal review process.

Having worked in healthcare, the burning question I have is what happened to "first, do no harm", the very foundation of the Hippocratic oath, throughout all of this? We always say "system failures" and bandy it around here, but in this instance, and very much in healthcare, the system is people. They are the most valuable asset. How do we move forward from here in terms of rebuilding trust and bringing a culture of truthfulness? We must refer to Maslow's hierarchy of needs. We must have a safe work environment where people are valued and where there is esteem, a sense of belonging and self-actualisation. Every team member has to be valued. Teams should be asked for their ideas before external consultants are brought in. We will get better buy-in and a stronger commitment. In terms of culture, high-performance team members can question one another to get the best level of participation from each member and strive to give the best performance possible, whether in the workplace, a healthcare environment, the judicial system or here on the floor of the House. All of this is to rebuild and encourage truthfulness and honesty.

Another area is governance. With responsibility must come accountability and openness. I have several questions on the National Treatment Purchase Fund and the treatment abroad scheme. These are symptoms of system failure. If the costs ploughed into these schemes went into the public system, would we have little or any need for them?

With regard to action, the recruitment of leaders should mean finding the best and most competent person for the job. It may not be necessary to revert CHI back to the HSE. Nine years ago CHI came from the HSE. The best person for the job should be given the job and not just the longest-serving people.

Mattie McGrath (Tipperary South, Independent)
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The findings on the use of pelvic osteotomy in children with developmental hip dysplasia raises deeply troubling concerns, not only for the families directly affected but for public confidence in paediatric care in this country. We are speaking about children, vulnerable young patients whose parents trusted the health system to do right by them. Serious questions now hang over whether some of these children underwent invasive surgery unnecessarily or without proper clinical justification. This is a frightening prospect and it demands full transparency, accountability and urgency in response.

I welcome the commissioning of an independent external medical audit but I believe we have to go outside of the country, and not to Northern Ireland, to get true independence for a proper audit. Let me be very clear. Families deserve to know the full truth and not be given sanitised summaries or bureaucratic brush offs. The audit must be thorough, independent in the true sense and patient focused. Anything less would be an insult to those children who may be living with lifelong consequences.

Furthermore, the lack of clear national guidelines or oversight on indicators for complex orthopaedic interventions such as pelvic osteotomy is unacceptable. This is not only a clinical matter. It is a systemic governance failure that must be addressed by the HSE, the Department of Health and the House. We need to listen to families, protect and support whistleblowers and ensure no child is ever again subjected to any procedure that may not be necessary. We have to have changes. There is no point in coming in here. We had an apology this evening, and a very profound one, from the Minister for Justice.

This is clearly unacceptable. It is scary. My late brother was a paediatrician of some renown and I cannot imagine what he would think about what is happening today. It is just not acceptable. CHI came from the HSE and it is being given back to the HSE now. There are fundamental failures there. We need true independence.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I thank the Deputies for their questions and contributions. I will answer as many questions as I can and I can provide a further briefing for Deputies on a technical basis. I am very happy to come to the committee where we can do more back and forth. It is important Deputies have the opportunity to contribute in the House and, as I always try to do, I will answer as many questions as I possibly can, recognising there is some duplication in those questions.

With regard to the questions on 2010, it is simply on the point of skeletal maturity. This was the initial look back to account for the children who are still children. I do not think it should necessarily be cut off at that point but I do think we should prioritise the children first before people who are now adults. I have a transitional model of care for those aged 16, 17 and 18 who are moving into adult care. I will discuss it with the CEO of the HSE. There is no desire to exclude and there never is.

In relation to the age of seven brought up by two Deputies, this was a clinical audit of children between the ages of 12 months and seven years. It was designed to try to capture the experience between 2021 and 2023. Again, it does not seek to exclude the other experience. It is about a clinical audit within these parameters. It is not limited to this. I have to be very clear it was an anonymised audit. I said this on Friday but please allow me to say again that there is no way a parent can ring up and ask whether their child was in the audit. I do not know and CHI does not know. By definition, it was an anonymised clinical audit.

While we are prioritising this, the follow up and the care is most important. Let me say several things. I completely respect that parents should not have to walk into a hospital where they have had, or feel they have had or worry they have had, a negative experience. We need to provide follow up but there has to be a measure of flexibility in it. I will discuss this with the HSE and CHI. I do not expect parents to have to go back to the same clinician or go through the same process. This will require us to have more flexibility.

Deputies also referenced the impact on service delivery, which has to be taken into account. We have a finite number of healthcare professionals. We are trying to grow more. There is an interplay between these different things.

The other expert review panel necessarily must be independent and external. I appreciate there are different perspectives on when I should have commissioned it but having received the report it is very important to get the recommendations and act on them expeditiously. I appreciate some Deputies would have taken a different approach. That is as may be; the important thing is that it is done as quickly as possible.

On the letter from Cappagh, I have confirmed with the CEO of the HSE that it went to approximately 20 people. It was the same group but for a different reason. It is slightly different. The letters have not yet issued, either to Cappagh or anywhere else, as I understand it. To be clear, those parents got a call this morning to say they could, of course, bring both parents or additional guardians or whatever else. That is something slightly different and not related to this.

I recognise the limitations with the phone line. It really was an effort to provide some answers to people over the weekend. The people answering those questions do not have any more information than I do. It was an initial signposting opportunity to have a clinical ear for parents at the earliest stage over the weekend, rather than leaving them in total silence.

Other questions have been raised regarding the accountability and the why. Many different questions have been asked on this. My broad view on accountability in relation to the individual clinicians is that there really are two mechanisms available for it. These are within the employment law structure and within the professional registration regulations. I do not have the capacity to fire a consultant in any context. Even if we think about the circumstances relating to Limerick, where the CEO of the HSE took various steps against people working in the healthcare system, those issues went through a court process. That is well publicised. This is with regard to even taking those different steps.

There is an imbalance with regard to the fair procedures individuals have the protection of in all cases, not only in the criminal process but in employment law processes and other accountability processes. This is with regard to the balance of protection given to the individual and their fair procedures, which are constitutional protections, versus the balance of the broad public good and getting information out there. We have to go through fair processes and behave in the correct way. There are good reasons for this but I wonder about the interplay over time and it is something the House should reflect on more broadly.

To answer a question asked by Deputy Rice, it is the case that explanations were advanced by surgeons which were discounted by the auditor. It is, therefore, the case that surgeons were contesting, at least within the audit process, the findings and advancing alternative explanations, which did not stand up. I am not aware of legal proceedings but this does not mean they will not be taken.

In relation to trust in the running of CHI more broadly, I have said clearly, and let me say again, this is something I am looking at in the round. There is a way to go on this and I will work with Deputies, particularly those on the health committee, on this.

The question of why has come up in a range of ways, with regard to motive and financial issues. There is a range of questions.

The straight answer is that I do not know the answer to that at this point, nor was it investigated in the clinical audit, although it is an exceptionally important question, as the Taoiseach articulated this morning. I would like to take steps to reflect on how we might get to the bottom of it, recognising that it is important that we also get the Nayagam report, which is linked to these different issues within orthopaedic surgery. Perhaps Deputies would allow me to get that report also and then reflect on those questions about motivation and how we might get better answers about it. I am not discounting anything about motivation and I am always interested in hearing Deputies' perspectives on it. However, let us perhaps get the Nayagam report and then reflect on how to think about the mechanism for that as well.

On the public-private system more broadly, I want it to be clear that I am an advocate of the public health system. If people want to have private health insurance and go to private hospitals, they are welcome to do so. This is a free country. However, I am a Minister trying to implement a public system with no other interest in it. I am an advocate of the full implementation of the public-only consultant contract. I will be taking further steps to remove the perverse incentives, or whatever people want to call them, that feature today because of the overhanging mix of public and private activity. I will not be dissuaded from that. That is important. However, it is also important that we use the levers we have to address the waiting lists where we can because that means our constituents, our people, getting operations today instead of some other time, while we all go on this transition together. I am an advocate of a public healthcare system. There is no advantage to having insurance in the paediatric system in particular and I do not want to see hospitals asking people whether they have insurance ever again. It is not important or relevant in a public hospital. I wanted to clarify that in case it needed clarification.

While I have tried to answer as many questions as I can on this report, I appreciate that I have spoken for almost 25 minutes between the beginning and the end of the debate in a very governance-focused, executive way, trying to answer the questions that were rightly asked and to set a direction of policy change and accountability. I will use my last two minutes to just speak about it as a public representative.

In the same way as others have very personal concerns about what has happened, I am aware of the impact of surgeries that were not warranted being done on children. I am aware of the feeling parents will have had when they heard that a surgery was warranted and made a decision either to have it or not have it as the case may be. The responsibility parents take upon themselves to follow clinical advice and the lack of alternative information available to them is like a Chinese sign being on the wall and the doctor the only person who can read Chinese. People have no choice in many ways but to follow the guidance. The responsibility a clinician holds is enormous and where it has been used in a way that is wrong, it is problematic, but where it is used in a way that is casually wrong and has implications for the small bodies of small children is unconscionable. I wanted to take the time to say that, so my response is not removed from the feeling of these things and overly focused on the executive response, which is appropriate and necessary. It is important that I am held accountable, but I wanted to take the opportunity to recognise that this is deeply hurtful. It has caused enormous worry to many parents who thought they were taking the right steps on behalf of their children in a properly governed, properly functional system with professional consultants making correct decisions. I want that other perspective also to be heard clearly. Ministers of State have articulated it. Deputies on both sides of the House have articulated it. We do so as a collective and I wanted to take the time to make sure it was done by me as well.

Ruairí Ó Murchú (Louth, Sinn Fein)
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Can we get a mechanism for the payment of third party reviews as promised?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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Yes, I will work on that with the HSE.