Wednesday, 10 November 2021
Nithe i dtosach suíonna - Commencement Matters
I want the Minister for the Health to make a statement on the disposal of baby organs in Cork University Hospital.This is probably one of the most troubling cases I have come across in my workload in recent weeks.
On 28 September, an "RTÉ Investigates" programme showed an unfortunate incident in the maternity hospital in Cork, where 18 families were told the news that their children's organs had been disposed of. Subsequent to that, one of those families contacted my office and they were very irate about how this was dealt with. I have had two meetings with them about this issue. Seventeen families were informed of the news; the 18th family found out on the eve of the programme's broadcast. On 28 September, one family got a phone call to inform them that an "RTÉ Investigates" programme would be aired that night with evidence relating to this issue outlined. They were told their poor baby's organs were cremated, but they were actually incinerated. They were not aware of all the evidence until they watched the "RTÉ Investigates" programme. It was a shocking programme in many ways. It involved 18 families and a breach of faith in respect of the organs of their loved ones who died. The 18th family had hoped and agreed that the organs of their child would be buried in the angels' plot in CUH, which was appropriate. They had the child baptised according to their religious beliefs. They wanted the child to be part of their family. That was all shattered when they got the news, literally on "RTÉ Investigates", that the organs of their deceased child had been incinerated in Belgium alongside waste. There has been a breach of faith here that will take an awful lot of work to rebuild. We need an urgent review of how this happened and, more importantly, an urgent review of this case in particular. One family was not informed. One family found out only on the eve of the programme's broadcast. One family had to sit down, watch the programme and learn that way where their child's organs ended up. That was inappropriate.
There needs to be a better way to do business. I have been involved in public life since 2003. Never have I seen a case such as this. We have no real line of communication put in place that would have ensured that these families were appropriately informed of the evidence of what had happened and how the breach of trust had happened.
We have a body of work to do. I will forward the Minister of State the information on this family after this session. The family needs to be contacted not by liaison people from CUH but by the senior staff of CUH and the HSE to explain who was involved and how it transpired that they were not made aware of this incident until hours before information on it was aired on RTÉ. There also needs to be a major change in the law. My understanding is that there is only a guideline for how these loved ones' organs are dealt with in a morgue. That is not appropriate. We now need legislation brought before the Houses of the Oireachtas to ensure that people are empowered such that when it comes to these issues they have the law on their side, they have the right to make sure justice will be done and their loved ones' organs will be taken care of appropriately.
This is a frightening case. It is beyond belief. It is a betrayal of human life and a betrayal of so many families. We need to come clean here. We need to deal with this family. We also need to deal with the law and we all need to put in place an assurance that never, ever again will we have a scenario in which organs are shipped to Belgium as waste and incinerated without the approval of the family. It is a sin and a crime, and I hope the Department will take heed and do something about these issues.
The Senator has used the words "shocking", "heartbreaking" and "a breach of faith". There is not one word he has said that I disagree with. I feel so much for the 18 families. I did not realise that one family found out on the eve of the "RTÉ Investigates" programme and that the other 17 families were informed before then. There are no excuses for that, and nothing I can say here will give comfort to the 18 families, not least the one family that was not included. It is absolutely heartbreaking. I was very upset when I heard about these much-wanted, loved babies' organs.
My colleagues and I are aware of the hurt this incident has caused to the families affected by the incident in Cork University Hospital. These families have been through the tragedy of having lost a beloved child, and it is absolutely unacceptable to me and to the Minister, Deputy Stephen Donnelly, that the organs of their children were disposed of in such a manner. There are no words that will ever give these families comfort. While it is not appropriate to comment on individual cases, I wish to accept and acknowledge the bravery of the couple who spoke about their experience and heartbreak on the "RTÉ Investigates" programme on 28 September and the other families who shared their experiences on 19 October. These are parents who have suffered the loss of a child, and this extremely distressing situation should not have happened as it has only added to their distress and grief. Not only did they lose their loved, wanted babies, but to learn in such a way how their babies were disposed of - there are no words to describe it.
The Department of Health is advised that the HSE, the South/South West Hospital Group, CUH and Cork University Maternity Hospital have apologised to the bereaved families and very much regret the incident. The Minister for Health and the HSE are committed to ensuring there is learning across the health services to prevent such events happening again. This can never happen again. The Senator spoke about changing the law. The HSE has advised that a systems analysis review is being undertaken by the South/South West Hospital Group. The purpose of that review is to find answers as to what happened, why and what can be done to reduce the risk of it happening again. However, reducing the risk is enough. It cannot happen again. I would have zero tolerance for it. We cannot only reduce the risk of this happening again; it cannot happen again.
The HSE advises that the review team met last week to review queries raised by families and to plan meetings with families who wish to engage with the review. Family meetings will be offered on 22 November and 24 November. The timeline for completion of the review will depend on whether there is a requirement to reinterview any staff regarding any new issues raised by families. The review team will further consider the issues after those meetings. The South/South West Hospital Group advises that it will act on any recommendations emerging from the review. Open disclosure with the families involved is an ongoing process and continues for a considerable time in the aftermath of an incident. This includes engagement in the review process and in sharing the review with the families.
As for legislation, which the Senator raised, the human tissue (transplantation, post-mortem, anatomical examination, and public display) Bill will implement the key recommendation of the Madden report that no hospital post-mortem examination should be carried out and no tissue retained for any purpose whatsoever without the informed consent of the family or next of kin. That would have prevented this incident if it had been in place. The Bill will ensure that the principles of protection of the bodily integrity of the individual before and after death, respect for the autonomy of the individual, and the rights of the bereaved are enshrined in legislation.
I stand here as Minister of State with responsibility for older people and mental health in the Department of Health. I can only apologise to these families. I am heartbroken for them. It is an absolutely awful tragedy, it is shocking and it is an awful breach of trust for these families and their beloved babies.
I thank the Minister of State for her response and her compassion regarding this incident. Yes, it really was a breach of trust. The lack of communication, or the breakdown in communication, needs to be looked at directly by the HSE. The communication lines were not appropriate, they did not work and they failed this family in particular. The review team needs to look at that when it meets. The meetings of 22 November and 24 November should be held both physically and online. Some of the families will want to attend online, and that needs to be accommodated. I hope the Minister of State will make sure that at some stage, sooner rather than later, senior members of the maternity services in Cork will meet these families.They are meeting a liaison officer at the moment. She is doing her best, but that is not appropriate. Senior consultants and senior staff in CUH have never spoken to these families. That is not the game. Responsibility needs to be taken at the very top. We must prioritise this legislation. It cannot be put on the long finger. Guidelines have previously been breached. This is not the first time it has happened; we have seen breaches in guidelines before. This legislation needs to be prioritised by our parties in government during the next session of sittings in the Dáil and the Seanad.
I do not disagree with anything the Senator has said about the breakdown in communication. I will ensure that both options are available if some families want to meet in person and others want to meet online. How they engage will depend on how those families want to address the matter.
The Senator is right about the legislation. It is hugely important that we do not lose any more time on it.
The South/Southwest Hospital Group has confirmed that the capacity issue around cemetery places has now been addressed with a new plot in St. Mary's Cemetery in Curraghkippane, just outside Cork city. I will certainly bring back to Government the Senator's comments.