Trevor Ó Clochartaigh (Sinn Fein)
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Fáiltím roimh an Aire Stáit. Táim ag ardú cás iontach brónach, cás Aibha Conroy, as Gabhla i gConamara, a bhásaigh go tragóideach cúpla bliain ó shin. I am raising a very sad case with the Minister of State, the case of Aibha Conroy, of which she may be well aware. It was the subject of a number of pieces on "Prime Time" recently.

Aibha was the daughter of John and Kathleen Conroy and in 2010 they noted that she was not well. She was brought to University Hospital Galway with suspected hypoglycaemia. She was discharged after a couple of days and was brought in again a couple of months later. She was seen by the same doctor, had a similar episode and was discharged once more. A little later there was an outpatient appointment where her mother raised issues. She was very concerned about her daughter's health and her situation. Perhaps a month or so later the child was hospitalised again. She was in a very serious state and was transferred to Temple Street hospital, resulting in her death, at six years of age, on 14 December 2011.

This was obviously very traumatic for the family concerned, but the issues I am raising now relate to the issues they have had since then in trying to find out what happened and to bring some kind of closure to the situation. They made complaints to the Medical Council in 2012, as far as I understand, and they felt there was a case to be heard. They were moving forward to try to have that case heard with the Medical Council and then the Corbally High Court ruling kicked in, which would have changed the terms of reference of any hearing that could have been held. They felt their hearing was then fast-tracked by the Medical Council and a finding was made before the Corbally High Court decision was made and, therefore, they are not happy that they got a proper hearing.

They felt they had no other recourse to justice than to go down the route of the Coroner's Court, so in the last two weeks, the coroner returned a verdict of medical misadventure in Aibha's case. The family said at that stage that they felt vindicated in their campaign for answers regarding Aibha's care and treatment during her short life. The coroner said the verdict of medical misadventure takes into account risk factors that arose in evidence during the inquest into Aibha's death and he identified the lack of critical blood samples to determine whether Aibha had an underlying metabolic or endocrinal issue as a risk factor and noted that the cortisol test could not be relied upon. The coroner also said there were only two verdict options open to him: medical misadventure or a narrative verdict. He is quoted in the media as saying:

At inquests we are not concerned with what might have happened, we are concerned with what happened. The critical tests were not performed.

The solicitor thanked the coroner on behalf of the family, because it was a very long sitting of the Coroner's Court. I think it was the longest one in the history of the State.

The solicitor talks about the Conroys' challenge being akin to climbing Mount Everest. They really felt they were battling against the system to find answers. Even after all that, they bear no ill-will towards any of the medics. The solicitor said at the time that the family knew none of the doctors or nurses intended this to happen. It seems to point to a systemic issue, that where certain tests were done or not done, or results should have been picked up on, that did not happen. I spoke to Kathleen Conroy recently and the family really wants to make sure something like this cannot happen again, that the systems at the Department and the Minister are taking on board what the coroner has said in his findings that the systems issues that were there, which may have led to the death of Aibha are being sorted out and that these types of things cannot happen again.They will probably not rest assured until they see that is the case and that no other family is placed in the same position as them. I look forward to the response of the Minister of State.

Kathleen Lynch (Cork North Central, Labour)
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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?

Trevor Ó Clochartaigh (Sinn Fein)
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I concur fully with the sentiments expressed by the Minister of State at the end of her contribution. The hospital does not intend to carry out any further review at this stage and will discuss it at its serious incident management team meeting. Based on that, and because the hospital group was involved in the whole case, does the Minister of State not think there is a case for the carrying out of an independent review by the Department of Health to examine the findings of the coroner and make sure that everything that needs to be implemented will be implemented so that this type of thing cannot happen again?

Kathleen Lynch (Cork North Central, Labour)
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An expert witness from outside of the State advised the coroner, which I have always believed is essential. I have never believed that we should investigate ourselves. Such independent expertise from outside the State is crucial. The answer reads badly in so far as it appears as though the case has been investigated and we are moving on. That is not quite what will happen. A whole new process is now in place to examine critical incidents or things that should not have happened to make sure that lessons are learned and that, in the event that any other child or adult presents in such circumstances, a process is in place to ensure that everything is picked up on. It is not simply a case of the matter being discussed at the next meeting. It is a process, and different processes will be put in place to ensure this does not happen again. As I have said, none of us can guarantee the future, something on which we can all agree. In the event that it is possible to ensure that events such as this do not happen again, the process is now being worked on.