Eugene Regan (Fine Gael)

No doubt this is one of those terrible tragedies about which it is difficult to speak. Suicide is always a difficult subject, particularly in this case when it involves an entire family. The "what if" question in a suicide situation is especially difficult, both for all the members of the wider family and all those who had any interaction with the people who, essentially, are the victims of this situation.

The report is comprehensive and detailed and makes some key recommendations. Those of which we can read seem very relevant to improving the system of health care and care of children.

However, there are some flaws in this report. One of the fundamental flaws is not in the terms of reference which have been given but in the interpretation of the terms of reference. The terms of reference include: "To identify the services sought or required and contacts made by or in respect of the Dunne family from public and other relevant services." The next main provision is: "To examine the way in which public and other relevant services ... responded to any requests and contacts ... discharged their functions ... [and] ... co-operated with each other. This is interpreted to mean that it must be examined in a broad sense, that the terms of reference, "require them to examine the provision of public and other relevant services rather than the performance of any individual person involved in the provision of such services", and yet it goes on to state that, necessarily, "an analysis of service provision will involve consideration of its provision by individuals". Therefore, there is a contradiction in the interpretation of the terms of reference and how the inquiry team came to this conclusion is puzzling.

The section of the report dealing with the interpretation of the terms of reference states: "It is the view of the Inquiry Team that the identity of each person has been protected to the extent possible consistent with the fulfilment by the Inquiry of its terms of reference." If that is so, why is there the various instances of editing to which I will refer. It states in its interpretation of the terms of reference that, "the Inquiry Team has endeavoured not to attribute fault to or comment adversely on any individual". In a somewhat contradictory statement the report states that where adverse comments are made in respect of individuals, they would be advised and be given the opportunity to make a submission.

Why, if we are holding an inquiry and the Government wants to get to the bottom of a subject, do we speak in such general terms? Why do we not identify those who are responsible? I am not suggesting in this inquiry that any individuals are particularly responsible for specific faults which led to this specific tragic event, but the entire methodology is flawed. I do not know who influenced or suggested this interpretation to those carrying out this inquiry, but it destroys confidence in so many other such inquiries into what went wrong in specific individual cases. Why not identify people? Why not get to the bottom of these issues? Then we can learn. However, we cannot learn from generalised findings and recommendations which do not attribute any responsibility or accountability to an individual. Where those who operate the system at no point feel that they have a responsibility because they will not be named or identified or have blame attributed to them under any circumstances, there are no consequences. How can anyone be confident that the system can be improved by virtue of this type of inquiry? This is a general point on which the Minister of State may have opinions. Perhaps he will explain the rationale for this approach and whether it was the intention of the inquiry's terms of reference. He made a statement to the effect that the inquiry was about learning, not about apportioning blame, which suggests that he endorses this methodology. This is where the problem lies, as we are failing to improve the health care system, the operational systems and the sense of personal responsibility.

I do not know what the problem is with the Fine Gael motion, which is to have the report referred in full to the Joint Committee on Health and Children for its consideration of the report's substance, submissions and recommendations. This anodyne amendment compliments the Minister of State. In fairness, the report was commissioned and presented, but I qualify my compliment in terms of the manner in which it was presented. I draw the House's attention to one phrase in the amending counter motion. It states: "contingent on legal advice, to refer the recommendations, including those redacted, to the Joint Oireachtas Committee on Health and Children for their information and consideration with a view to the State taking on all the learning to be gained from this Report". This phrase often appears in discussions on this type of case. We are constantly in a learning process, but there is no responsibility, past or future, or accountability.

The report is meant to guide the House in the formation of policy and legislation. If recommendations are edited, redacted and deleted, how can the report provide a guide to policy? It is said that the Attorney General and outside counsel have advised on the necessity to edit the document, but has the former advised——