Mary Lou McDonald (Dublin Central, Sinn Fein)
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The independent audit of hip surgeries performed at Children's Health Ireland, CHI, and the National Orthopaedic Hospital Cappagh is damning. It makes for devastating reading for parents and families who are caught up in this scandal. One of those parents, a heartbroken mother, contacted us. Her daughter was just four when she had surgery on both hips. This is mother is convinced, based on her reading of the audit report, that her daughter did not require either operation. Here is what she wrote:

I'm gutted to have let my daughter down. I'm the person who is supposed to protect her. I'll have to live with that. After her operation, I'll never forget what she said to me, 'I didn't ask to come here, Mammy.' She walked into that hospital but had to be carried out. Learn how to walk again. Night after night, for weeks, screaming and crying from muscle spasms. Thank God she is now back to herself, but I have no doubt that she will have those memories for life. I have no words left, only tears.

Some 2,200 letters have been sent to parents. All of them now ask themselves the same question, "Was my child put through the trauma of surgery that wasn't needed?" The Taoiseach had said that the response to this scandal would be to put the children affected and parents first, yet families heard of the publication of the audit through the media and were not provided with copies before it was published. The parents also report that they are being fobbed off by the hotline set up to deal with their queries.

Last night, parents received their first communication from the hospitals since this audit was published. It is a very blunt, insensitive letter inviting their children to attend appointments. Written in bold, it is stated that only one parent can attend. Who do these people think they, are treating distressed parents like that?

At a meeting on Sunday evening, parents expressed anger, naturally, and deep concern about the independence of CHI's review and assessment processes. They ask how the very organisation that presided over this scandal can have any involvement in any review. CHI is mired in scandal and catastrophic governance failures relating to unnecessary hip surgeries on children and unauthorised springs being inserted into children's spines. We also hear that a CHI consultant delayed treatment, referred public patients to his own private clinic and was paid thousands of euro through the National Treatment Purchase Fund.

The failure of the Government to immediately establish and put beyond any doubt the absolute independence of all of the expert panel has led to a real fear among parents that this will be largely dealt with in-house by CHI. There is no excuse for the delay. The Government has been aware of this scandal for an entire year. Its failure to prepare means that parents now face the cruel prospect of waiting months, with stress and worry, before they can find out if their children were operated on unnecessarily. Beidh tuismitheoirí fágtha cúpla mí ag fanacht le fáil amach ar cuireadh a leanbh faoi obráid gan ghá. Is é sin an toradh ar chur chuige mall an Rialtais. The Government needs to get its act together and do right by these families. Can the Taoiseach guarantee that every child who has had these hip surgeries since 2010 will have their case reviewed to determine if the operation was necessary? Crucially, can he assure parents that the expert panel will be entirely independent of CHI?

Micheál Martin (Cork South-Central, Fianna Fail)
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Is é an príomhrud, agus an rud is tábhachtaí, ná na leanaí a fuair na hobráidí seo, agus na tuismitheoirí go háirithe. Is é príomhaidhm an Rialtais ná tacaíocht agus cabhair a thabhairt do na teaghlaigh éagsúla. Tá mé an-bhuartha ar fad faoin méid atá á shoiléiriú ag an tuarascáil seo a foilsíodh an Aoine seo chaite. Our overriding consideration will be the children upon whom these operations were carried out and their families. That is the number one priority of the Government and, indeed, of the Minister for Health. The findings of the audit are shocking and grave Our first thoughts have to be with the children and their families. In terms of the communications, I will make sure there should not be a limit of one parent being allowed to attend any meeting. In my view, parents, or at least a mother or a father, may require support at such meetings, and that should be readily facilitated.

I make the point that the audit was external. It is unfair to cast aspersions on the Government's motivation and suggest that somehow this could be in-house. The audit was external, conducted by Simon Thomas, consultant orthopaedic surgeon at Bristol Royal Hospital for Children. On the figures, some 60% of procedures in Temple Street were not clinically indicated in accordance with the criteria established by the author. In Cappagh, 79% were not clinically indicated. That is beyond comprehension, but we need to find out why and how it happened. The most immediate priority has to be the follow-up for the families. In that context, individualised letters have been sent out by CHI and Cappagh. An expert reference group, with international input, is developing the criteria against which future multidisciplinary team assessments will be made. That will be in place within the next two months.

In terms of the retrospective review, fundamentally, it has to be external. A separate process involving external experts is being established for this purpose by the HSE.

The Minister has asked the RCSI to assist in bringing together a multidisciplinary external team to examine all cases going back over the period of time in question, which covers about a 15-year period in terms of skeletal maturity and so forth. The Minister for Health is expediting the establishment and engagement of external experts to review these cases, not just surgeons, but radiographers and other disciplines as well. The issues raise the most fundamental concerns about clinical performance itself, clinical governance and overall governance within CHI.

The Deputy referred to other matters in respect of a report published in The Sunday Times. The Minister was notified of this on Saturday afternoon via a media inquiry. She had not been alerted to the existence of that report of an internal inquiry conducted by CHI. That also makes for shocking reading of the most profound kind, which not just goes to the heart of the misuse of NTPF funding but more seriously raises fundamental concerns at that time about safety for children receiving surgery.

Mary Lou McDonald (Dublin Central, Sinn Fein)
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It is now abundantly clear for anyone who wishes to see that clinical governance and governance in general at CHI is absolutely a fiasco. I know that three members of the board have resigned. I put it to the Taoiseach that the remaining members should follow suit because clearly what is needed here now is root-and-branch reform, change, transparency and accountability. I voice concern over the full independence of this reference group from CHI because that is the concern that parents are bringing to us. They have been catastrophically failed. Trust levels are on the floor. This involves perhaps unnecessary surgery on very young children. If the Taoiseach is true to his word that parents and children come first, then absolute independence needs to be given. Can he give us that assurance? Can he also assure us that the case of every child who had surgery since 2010 every will be independently investigated and reviewed?

Micheál Martin (Cork South-Central, Fianna Fail)
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The immediate priority is the clinical follow-up and care of patients who have undergone this surgery. This represents a very fundamental and serious breach of trust. As I have said, there will have to be further investigations as to why this occurred and how it was allowed to occur. I have said the retrospective look back will have to be externally done, involving multidisciplinary teams to make sure that independence and that confidence is in the process from day one. I make the point, of course, that 98% of the procedures and surgeries within in Crumlin were clinically indicated. I acknowledge there are many very good high-quality people working in CHI generally. There are very basic issues of clinical governance, clinical leadership and clinical performance. There are issues with overall governance of the hospital that are clearly raised and emerge from this situation.

Ivana Bacik (Dublin Bay South, Labour)
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The controversy surrounding Children’s Health Ireland has somehow managed to escalate yet again over the recent days. Instead of focusing on the vital task of caring for our children, CHI is presiding over an increasingly chaotic string of failures, failures with devastating consequences for sick children and their families. The Taoiseach mentioned breaches of trust, which are clearly evident too. We have had the use of unapproved non-surgical springs in children's surgery, and horrifically the carrying out of unnecessary pelvic bone operations on children to the desperate distress of parents and the children themselves as they learn what has gone on.

The Taoiseach quoted the stark figures with 60% of surgeries at Temple Street not having been clinically indicated. Yet more horrors were outlined by John Mooney at the weekend.

He described the abandonment of vulnerable children, actually described by staff as orphans, left stranded in hospital receiving substandard care long after best practice indicated they should have been moved on; the carrying out of specific treatments, apparently for the personal profit of certain clinicians; and a bitter and toxic internal culture within CHI described as "chaos behind closed doors". It all begs the question: what on earth is going on within CHI? Who is actually in charge? That last is a question that has become even more urgent as we learn that three more board members resigned just today; a drip-feed of resignations, we might say, after the stepping down of the chair in April.

By our count, there have now been four externally commissioned reviews of the care provided by CHI in the past three years, which show failures of culture and failures of clinical care and management that are systemic and endemic. What is most important now is that children and their families will see accountability and justice for the failings of the past. We need an assurance that children will receive the best care today and into the future. We need to see accountability, not just individual heads rolling and nothing else changing. We need to ask and answer serious questions about whether CHI has capacity as an entity to do its job. This requires the Taoiseach’s urgent attention and that of the health Minister. We welcome the Minister, Deputy Carroll MacNeill’s engagement on the issue over the weekend - I listened carefully to her interview just an hour ago on the radio - but we need decisive action. As my colleague Deputy Sherlock, our health spokesperson, said, CHI must now come under the direct control and oversight of the HSE. Until that happens, it is very hard to see accountability. What we have now is the ridiculous situation whereby the HSE is answering questions about scandals for which it does not have direct responsibility.

In December of last year, The Irish Timesreported that former health Minister, Stephen Donnelly, had sought legal advice on whether the State had power to take over the running of children’s hospital services in Dublin, and that advice was reportedly sought due to concern over issues around scoliosis surgery waiting lists, delays in appointments and outrageous overspends with the national children’s hospital. Now, we have these recent very serious revelations. Can the Taoiseach give assurances that there will be real accountability for all the many failures within CHI? What can he say to assure us there will be real change?

Micheál Martin (Cork South-Central, Fianna Fail)
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First of all, there has to be accountability. I would agree with the Deputy in that respect. Also, one would have thought that the era of an individual consultant being an independent republic was long gone. That is clearly not the case in the context of these reports and the one from which the Deputy has been quoting, which is the subject matter of The Sunday Times articles, if I am correct.

The imperative of multidisciplinary teams being in place across the entire system cannot be overstated. That report the Deputy referred to, which I had a look at late last night, is deeply worrying. It relates to a whole range of issues but the more fundamental one, in terms of the overall context of the language the Deputy used, really speaks to an environment that is, to put it mildly, not optimal for the safety of patients, and an absence of a proper team-based, holistic ethos within the CHI group and within the hospital in particular.

The Minister said earlier that governance was an issue of fundamental concern to her also. We need an immediate clinical follow-up for those impacted by the hip surgery and pelvic surgery and then, in addition to that, we need accountability and to find out why and how so many children who did not require operations had operations.

Third, the Minister has appointed or is in the process of appointing two members of the HSE board to the CHI board. We have to evolve the governance now of CHI, conscious that we are moving to a new hospital as well, which in itself will demand significant governance standards and capacity. We have to do so in a way that does not disrupt the thousands of procedures that are ongoing within CHI. A new CEO has come on board there. We have to work with the new CEO. I know the Minister and the HSE will work closely to buttress and underpin governance now in the short term within CHI.

We will have to look at a sensible evolutionary pathway to change governance.

I would make the overall point that, in health historically, institutions have been too strong, to the detriment of patients. In education, the big revolution was that the learner became central to education, not the institutions. In health, the patient must be central, not the ethos of any particular foundation, any particular historic hospital or whatever else. Invariably, new structures get formed to accommodate the historical background of certain hospitals. That is what has happened essentially in terms of CHI. We need to move on and evolve this into a proper governance framework.

Ivana Bacik (Dublin Bay South, Labour)
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I agree with the Taoiseach that this is clearly an environmental, cultural and systemic failure. Of course, the parents and children most directly and desperately affected urgently require an independent review. However, we need to hear more from the Taoiseach and the Minister for Health – the Taoiseach is, of course, a former health Minister – about the systemic changes that will be made to address the much bigger failing that is clearly at the heart of these terrible individual tragedies for children who are now being told they may have had unnecessary surgery.

What is the Government going to do to address the systemic and environmental issues in CHI? A drip-feed of resignations from the board is simply not enough. That is just twiddling at the edges. We need to know what will change to make sure that there is a proper culture in CHI that ensures individual clinicians cannot run amok, abuse the National Treatment Purchase Fund or carry out procedures in a sort of vacuum and splendid isolation without the holistic approach the Taoiseach rightly said was necessary. Parents and children require a sense of systemic change.

Micheál Martin (Cork South-Central, Fianna Fail)
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I agree, although I note that, maybe not Deputy Bacik, but others last week were looking for the resignation of the board or something tantamount to that. That was put to us. A drip-feed of resignations is not the answer, obviously. The Minister has been clear on the number and series of steps. The immediate one is clinical follow-up that will be external, independent and give the necessary reassurance to parents, what could be young teenagers now and children in respect of the surgery they went through. They could have that external look back and it would be independent.

Within CHI, there has to be a fundamental commitment to a multidisciplinary team-based approach across the entirety of all disciplines in CHI, including surgical disciplines and all other areas of medicine. That is absolutely critical. The Minister has said that governance is a key issue. I agree with the Minister. I think there has to be a fundamental look at governance as well in the immediate time ahead, but we must avoid-----

Ivana Bacik (Dublin Bay South, Labour)
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What about the HSE?

Micheál Martin (Cork South-Central, Fianna Fail)
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I am sorry. It will involve the HSE. We have to do things in a way that does not disrupt urgent procedures that children require today and next week.

Cian O'Callaghan (Dublin Bay North, Social Democrats)
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Children's Health Ireland is in crisis. Another three members of the board have resigned today. A succession of scandals has cast serious doubts on its capacity to provide quality healthcare to children in this country. A common thread in each of the scandals is an almost complete absence of clinical oversight. Medically questionable and unethical practices proliferated under the noses of highly paid clinical directors and management teams at CHI and Cappagh. The HSE and the Department of Health were either kept in the dark or did not notice. Clinical oversight and governance systems failed. Children were not protected. They suffered extremely painful hip surgeries. It is unthinkable to think that any child would be put through this trauma unnecessarily.

We now need all the facts and full transparency and accountability from Children's Health Ireland, but can we trust it to provide that? It sat on a 2021 report that was highly critical of one of its consultants. That report found the consultant earned more than €35,000 by keeping very young children on a waiting list for years. They were eventually treated using the NTPF when they were transferred to the consultant's weekend clinic, but they could have been treated by other doctors years earlier. When all of this was discovered, it was kept a secret and the consultant was allowed to retire and sail into the sunset.

The final audit of hip surgeries confirmed that nearly 80% at Cappagh and 60% at Temple Street could have been unnecessary.

The high prevalence of surgery at these hospitals was not a secret. The parents of some of the children were told they would not have been operated on if they were at Crumlin. At the time, they thought they were lucky. They were led to believe their children were getting cutting-edge treatment that was not available at Crumlin. Now, they fear their children suffered the agony and trauma of surgery unnecessarily.

The Taoiseach has said himself that the era of consultants being utterly unaccountable is meant to be over. The system of clinical directors was introduced in 2008 - nearly 20 years ago - but is it working? None of the issues identified in Children's Health Ireland was detected by clinical oversight. They came to light because of whistleblowers and a random review. Even when potential fraud and abuse of waiting lists were detected, the wagons were circled. The HSE, the Department of Health, the National Treatment Purchase Fund and the Medical Council were never notified.

Will the Taoiseach confirm that all of the children operated on will have access to an independent clinical audit by international experts? Will the Government commission a review of the system of clinical directors to determine why alarm bells did not ring?

Micheál Martin (Cork South-Central, Fianna Fail)
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Again, I reiterate that this is a shocking report into hip operations. For example, there is the variation between Crumlin at 98% that were clinically indicated - that has to be stressed - to only 60% in Temple Street and 21% in Cappagh. This variation alone, from an external independent author, sends all sorts of alarm bell ringing. We have to find out how that happened and why it happened. Why were children operated on who did not require any operation? It is incomprehensible and unethical. It is just unacceptable. We have to get to the bottom of this because it goes to the heart of trust and confidence in our health system and in clinical judgment and clinical performance. It goes to the heart of clinical performance, whether people like us saying it or not.

Equally, if we look at the report on the springs, I found it very difficult to comprehend how something that was not certified or CE standard was inserted into children. We get various communications, anonymously and so on, saying we misread it and we were too harsh on the individual consultant when we said certain things in the Dáil but it is a basic. We have a very sophisticated medical device industry in Ireland where the standards are the highest in the world. We produce hips in this country. We produce all sorts of orthopaedic products. Everything is about quality assurance and quality control, yet in one of our tertiary hospitals – I am sorry, but it is an orthopaedic hospital, not tertiary - springs were inserted into a child with no one making the assessment on whether they had gone through the proper process. It is incomprehensible this would happen.

To answer Deputy O'Callaghan's question, it does raise the most fundamental questions about the entire programme of clinical directorship and whether it is working, and it does need to be reviewed. The idea was a good idea. It is actually a good concept and a good idea but it does depend on everybody working as a team. We have had the dysplasia report on the hips. We are awaiting a further report on the operation of the paediatric spinal service, the Nayagam report. Now we have the internal enquiry that surfaced via the media, and which was not sent to the HSE or the Department from what we can establish and verify. Therefore, that report raises a series of issues also in terms of the governance question, safety questions, atmosphere and so on, which Deputy O'Callaghan has referenced.

Taking all of this in its totality, one has to state the obvious that we need to look fundamentally at the governance of CHI and we have to move quickly in the short term, as the Minister is, in ensuring two HSE board members are on the board but then, how do we evolve that further?

Cian O'Callaghan (Dublin Bay North, Social Democrats)
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We are talking about children, sometimes as young as the age of two and even younger, being operated on. What has happened is incomprehensible. When parents rang the phone line that was set up for them at the weekend all they were asked for was their contact details. None of the questions they asked could be answered by the people on the phone line. It is not an acceptable way to treat the parents.

The Taoiseach said that everything needs to be looked at and reviewed and that clinical oversight needs to be reviewed. Is he committing to carrying out a review of why the system of clinical directors here is failing? When will that review start? Will he give details about it? I do not want him to commentate on this. I want him, as Taoiseach, to give us hard details about what he will do in reviewing the failures of clinical oversight.

Micheál Martin (Cork South-Central, Fianna Fail)
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As I said, to be fair, the audit was external, which means, in anything we do will have that reassurance for families in terms of the independence of any external review. There will be a retrospective review of every case. The Minister has acted and the Government fully supports her in this series of actions.

The first priority is clinical follow-up for all those who had surgery and supporting their families in the process of the retrospective external review of their cases. In addition, the Minister is taking immediate steps to strengthen the board of CHI and to provide for stronger support from the HSE in its engagement with CHI. There will have to be accountability on all these issues. The Irish Medial Council is there, but we also have HIQA and others. We will pursue the matter on that basis but the first priority is to work on making sure we follow up comprehensively on behalf of the children involved and their families.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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I will talk about widows' pensions. Pensions for widows do not discriminate by age. Recipients can be in their 20s, 30s, 40s, 50s or any age. However, it is worrying for people. I will tell one or two stories. One is about a mother with three children whose husband died. They had a house with a mortgage and she is in receipt of the widow's pension for which she said she is grateful. However, if she is on sick leave from work, even though she is a PAYE worker who pays PRSI, she does not get sick pay because she is in receipt of a widow's pension.

A father with two children whose wife passed away due to cancer has one child in secondary school and one in primary school. He worked all his life and continues to work. He is in receipt of the widower's pension. It does not cover the loss of his partner but it helps him and his family to try to survive. If he is out of work tomorrow morning, he will not get a payment from his stamps if he is off long term, because he is in receipt of a widower's pension.

Will the Taoiseach rectify this so that if people who work are off sick and do not work, they receive a payment? All the different criteria from different employers only cover people up to X number of sick days. Some workplaces then require people to claim illness benefit but that is based on PRSI contributions, or stamps, and people cannot be in receipt of two government payments. This needs to be rectified for people who work and get sick because they cannot survive. As I said, they are thankful for what they get to help them to survive. It does not replace their loved ones but it helps them to try to cater for their families. Will the Government look at this? Will it introduce legislation to provide that people can receive widow or widower's payments if they work and are off sick? They should be entitled to their PRSI contributions, which they work to pay and to the widow's or widower's pension. This is what they are asking for. Can this be sorted out to make sure their families can survive? These are only some of the cases that were brought to my attention. Will the Taoiseach look at that?

The Taoiseach: I thank the Deputy for raising the issue. He made a number of fair points. When a widow loses her husband or a husband loses his wife, the cost of running a household does not go down. The costs are similar, if not additional in some respects depending on age and so on, with having to look after children if the parents return to work. It creates enormous challenges.

It is also a very lonely journey for quite a period. I will ask the Minister for Social Protection, Deputy Calleary, particularly in the context of the next budget, if he could examine the points the Deputy has raised and the various anomalies that potentially exist. The social protection is broad and has many different payments. Some of the policies are interrelated. If we move in one area, there is a ripple effect across the entire social protection system, although the status of the widow is worth considering, apart from the breadth of social protection payments that people receive. Generally, Departments are always worried about making exceptions for one particular category of person in receipt of payments in their systems but the Deputy has raised a number of important issues. I will ask the Minister to engage with the Deputy on this because he may have other examples, particularly on the sick pay argument. I will ask the Minister to pursue this. I will also engage with the Deputy in the context of the budget to see if there are other sensible or practical things we can do to alleviate the pressure and pain people go through in such circumstances.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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I thank the Taoiseach for his response and look forward to meeting with the Minister on this.

I am under no illusions; there are many criteria under different payments the Government must consider under different circumstances. When it comes to people losing a loved one, however, and they are trying to survive, whether they have children, there are massive overheads, even with current inflation costs and the challenges facing people. It is something that should be legislated for. If we can, we should do everything to help people in situations like that. There are other more complicated criteria but if someone is widowed, whether he or she is working but has paid PRSI contributions, it should not matter. It should not interfere with the widow's pension if he or she is out sick. I am trying to bridge that gap to ensure that if a person is out sick, hey or she does not have the worry of going further and further into debt, which causes worry for the whole family.

Micheál Martin (Cork South-Central, Fianna Fail)
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There is a complexity to the social protection system and if you move in one area, it can affect others. We are all familiar with meeting pensioners when knocking on the doors, who will say they lost their wife last year and found it very difficult because they still have the same heating bills, running expenses, rent or mortgage.

Richard O'Donoghue (Limerick County, Independent Ireland Party)
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People are dying younger than that.

Micheál Martin (Cork South-Central, Fianna Fail)
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Their expenditure had not gone down at all but their income had been halved in many instances. I will ask the Minister to look at this and we will revert to the Deputy on that.