Tuesday, 8 July 2008
I welcome the Minister of State, Deputy Mary Wallace, and thank her for taking this matter. I raise a set of circumstances to which I appreciate she will not be able to respond but which I hope she will pass on to the Department for further consideration.
I raise this matter as a result of the unfortunate death of a young woman in 2005 in Cork University Hospital. Her name was Catherine McCarthy, she was 42 years old and the mother of two young children. She presented at the hospital with an engorged stomach and was admitted to accident and emergency. As she had previously dealt with the hospital, she was referred to a consultant who was not on call at the time and as a result, she was not seen until the following day. Within a very short time — a day and a half — she was to lose her life due to a failure to properly diagnose her condition.
Her husband is a paramedic working at Cork University Hospital. Since her death, he has found it very difficult to get answers or to receive a satisfactory explanation of events as they unfolded. The first port of call would have been the hospital's risk assessment unit. Risk assessment units are common in all hospitals and in the HSE. When an unexplained death occurs, we should ensure an independent body is involved in the investigation. The investigation was carried out by the hospital. Legal action was taken and there was a settlement following a High Court case.
Mr. McCarthy subsequently went back to the HSE, southern region, and some assistance was offered by the head of hospital services. The circumstances of the case were reviewed by a national HSE officer responsible for risk assessment. However, it was a review of the procedures of Cork University Hospital in investigating the circumstances. Neither the initial investigation nor the subsequent review by the individual working for the HSE has provided sufficient information or an explanation for Mr. McCarthy in regard to what happened. What happens in the event of a negligent death, which has since been admitted by the HSE?
Exploring one final avenue, Mr. McCarthy wrote to the newly established Health Information and Quality Authority. He received a response stating that HIQA did not deal with complaints of this type referred in this way. If not, why does it not do so? I would have thought the establishment of HIQA was to inspire public confidence so that when incidents of this type occur, cases would be responded to quickly, diligently and thoroughly. All of the existing processes have been used and none have been adequate. The final process does not seem to address the concerns at the heart of this case.
There are severe inadequacies in the processes used to account for negligent deaths and through which those affected by such events can seek adequate redress, in terms of information, and draw a line under events of this type. I do not expect the Minister of State to respond to the set of circumstances I have explained but perhaps she can outline whether there is confidence in existing procedures. I would not share that confidence, if it exists. I hope the set of circumstances I have outlined will be relayed to the Department so that a more detailed response can be given.
I assure the Senator his concerns will be relayed to the Department. If we can get specific information for him, we will endeavour to do so. As the Senator said, the reply I will give on current policies on the investigation of deaths in hospitals through negligence and the adequacy of these policies will be of a general nature. It is regrettable that patients might be injured in our hospitals. We consider deaths that occur through negligence to be a very serious matter, particularly in the sad circumstances outlined by Senator Boyle. The Government is fully committed to improving patient safety to the greatest possible extent and a number of measures have been taken to further this aim.
The coronial system is the statutory system by which deaths that might have arisen from negligence are investigated. The current system here is based on the Coroners Act 1962 and the Coroners (Amendment) Act 2005. The coroner has the duty to hold an inquest on a death if he or she is of the opinion that the death may have occurred in a violent or unnatural manner. Medical practitioners who have reason to believe the deceased person died as a result of negligence, misconduct or malpractice on the part of others must immediately notify the coroner, within whose district the body of the deceased person lies, of the facts and circumstances relating to the death. Medical practitioners attending deaths in hospitals are subject to this legislation.
The coronial system was reviewed by the coroners' review group in 2000 and the coroners' rules committee in 2003 and legislative change is now in progress. In April 2007, the Minister for Justice, Equality and Law Reform published the Coroners Bill and announced the establishment of a coroner's service implementation office. The Bill is wide ranging, with particular emphasis on the modernisation of death investigation, post mortem and inquest procedures. The Coroners Bill comprehensively reforms the existing legislation and structures relating to coroners, provides for the establishment of a new coroner service and incorporates many of the recommendations made by the coroners' review group in 2000 and the coroners' rules committee in 2003. It provides for a fundamental change and improvement to the coronial death investigation process in Ireland to equip coroners to conduct the best possible death investigation and provide them with the necessary administrative and technical supports to carry out their functions.
The new coronial system will provide an enhanced service to the families of deceased persons and to society at large in explaining deaths and in drawing attention to possible public safety and health issues. The Bill lists types of death in the Third Schedule that shall be a reportable death for the purposes of the proposed Act. MRSA, for example, is listed as a reportable death. Persons obliged to report death to the coroner will now include any registered medical practitioner or registered nurse having had responsibility for or involvement in the care of the deceased person. The Bill provides a statutory framework extending the scope of the inquest from investigating the proximate medical cause of death to establishing in what wider circumstances the deceased met his or her death.
In addition to the requirements of the Coroners Act, staff at hospitals operated or funded by the HSE are required to report adverse clinical incidents and near misses to the STARSweb system operated by the clinical indemnity scheme, CIS. STARSweb, designed to capture all clinical adverse events and near misses, has been rolled out nationally. The numbers of adverse events notified to the system continue to rise each year. The system supports local risk management initiatives at enterprise level and allows for national trend analysis.
An important objective for the CIS is sharing of learning to support patient safety. Cases are subjected to analysis in order to capture any learning from them. Feedback is then provided to the individual enterprise and any generic lessons are communicated throughout the system using a variety of methods. The CIS also works in collaboration with the HSE and a large number of national and international bodies to support identification of best practice vis-À-vis patient safety and its implementation.
The Health Service Executive introduced its serious incident management policy in March of this year. This outlines what must be done in the event of a serious incident in order to adhere to the highest possible standards. Its purpose is to ensure an urgent, appropriate and proportionate response to all serious incidents. The policy and procedures apply to HSE employees and to agencies and services funded by the HSE. A serious incident is defined as an incident which involves or is likely to cause extreme harm or is likely to become a matter of significant concern to service users, employees or the public.
The HSE has established a serious incident management team to ensure the policy is fully implemented and this team will immediately take responsibility for managing any significant serious adverse event which occurs. The policy provides for consideration to be given to the need to suspend specific services and to ensure appropriate contingency arrangements. It also ensures that all service locations which may be at risk as a result of the serious incident are notified and checks whether a health professional over whom sufficient concerns arise worked elsewhere and for what time periods. This policy will be reviewed in the light of experience.
Senator Boyle mentioned the Health Information and Quality Authority. This was established in May of last year and its primary role is to set and monitor standards in our health services. The authority has already produced standards in a number of areas and monitoring to date includes a comprehensive national review of hygiene services in our acute care public hospitals.
The Health Service Executive has taken major initiatives in the improvement of quality and the management of risk. It has also developed an action plan on the prevention and control of health care associated infection, and implementation is ongoing. In January 2007, we established a commission on patient safety and quality assurance. The commission's terms of reference include a wide range of patient safety related issues. The commission is expected to report to the Minister later this month and its recommendations will be considered as soon as possible thereafter.
In conclusion, all possible steps must continue to be taken to ensure that adverse events in hospital are kept to an absolute minimum. When they occur, they must be dealt with and reported promptly and investigated appropriately. The Minister is satisfied that such steps are being taken and that priority is being given to the whole area of patient safety in the public health service.