Kathleen Lynch (Cork North Central, Labour) | Oireachtas source

I am not certain what language one should use when someone loses a child, because it is probably everyone's worst nightmare, especially when a child is of an age at which he or she is an integral part of the family. He or she would have entertained the family and driven them mad from time to time. More than anything else, he or she was a living, breathing personality. Through the Senator, I would like to convey not just my condolences but those of the Minister for Health. The loss of a child is a most tragic event whatever the circumstances, but in circumstances in which families feel it could have been avoided it is even more tragic. This week's events in the courts brought that home to us more clearly than anything else.

I am assured that, as the Senator said, a comprehensive and detailed inquest took place into this very sad death, and medical and nursing staff from Galway University Hospital fully engaged with the coroner in that process. In addition to the sworn evidence from hospital staff, I understand that the coroner was also provided with the testimony of an independent expert and that this assisted the coroner in reaching his verdict. Given the comprehensive nature of the inquest, I am informed that it is not the intention of the hospital to carry out any further review at this stage. However, I am advised by the Saolta University Health Care Group that the inquest findings will be reviewed at the next serious incident management team meeting, which is to take place on 18 November. Once the findings have been examined in detail, the group will immediately develop an action plan to identify all potential improvements in care pathways and processes. Any recommended changes will be implemented without delay in order to minimise the risk of a similar future event. The group is also in the process of recruiting a consultant paediatric endocrinologist to provide additional specialist expertise for Galway and surrounding areas. Interviews for this post, which will be based in Galway University Hospital, will take place in the coming weeks.

The delivery of health care is not without risk - I believe the Senator stated that himself - and the very understanding attitude of the Conroys shows that they accept that as well. It involves risk because, although it is improving, the science of medicine is far from perfect. The challenge we face is not the achievement of perfection but the development of a service in which the risk of harm and medical error is minimised and the capacity to identify it when it does occur is maximised.

It is equally vital that we establish the steps that need to be taken to prevent a recurrence of adverse events by ensuring that lessons are learned from situations in which error occurs and that these are shared across the system to improve the quality of care. The HSE and State Claims Agency open disclosure policy, which is designed to ensure an open and consistent approach to communication with patients and their families when things go wrong in the provision of health care, is one such system. It is important that patients and their families are kept informed and that feedback is forthcoming on investigations.

The HSE has now begun implementing the policy across all health and social care services. As the Senator will be aware, it is not just about acute hospitals. Things can happen outside that realm. Patient safety remains a key priority for me and for the Minister for Health, and we will do our utmost to support the HSE in any way possible in regard to the implementation of any additional measures arising from the outcome of this very tragic case.

I often think that even in the event of a tragic ending, it is how it is handled rather than the event itself that has the greatest impact. I know the Conroys are anxious that everything be put in place in order to ensure that no other family will face this event. I hope their efforts, together with the coroner's report and the establishment of the implementation team to ensure this does not happen again, will constitute a fitting tribute to their child, although they never wanted that. Who wants such a tribute to their child?