Joint Committee on Health debate -
Thursday, 10 Oct 2024

Apologies have been received from Senators Kyne and Black. This purpose of this meeting is for the joint committee to consider issues relating to University Hospital Limerick, UHL, in the context of the mid-west region with the Minister for Health, Deputy Stephen Donnelly. This meeting takes place following the recent publication of a report relating to the hospital. To commence the meeting's consideration of this matter, I am pleased to welcome the Minister for Health, Deputy Stephen Donnelly, who is accompanied by Ms Rachel Kenna, chief nursing officer; Ms Siobhán McArdle and Ms Tracey Conroy, assistant secretaries in the Department of Health; and Ms Sandra Broderick, HSE mid-west regional executive officer.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if witnesses' statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that any such direction is complied with.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I also remind members of the constitutional requirement that members must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any member participating via MS Teams that prior to making their contribution, they confirm they are on the grounds of the Leinster House campus.

To commence our consideration of issues relating to University Hospital Limerick in the context of the mid-west region, I invite the Minister, Deputy Donnelly, to make his opening remarks.

Gabhaim buíochas leis an gCathaoirleach. Good afternoon to him and to committee members. I thank them all for the invitation to speak on the critical issues relating to the delivery of safe, timely and effective care for the people of the mid west.

I would like to start today by stating clearly that additional capacity is needed in the mid-west to provide people with timely access to emergency care, to urgent care and to scheduled care. I have said this before and it is why I and this Government have allocated large sums of money to provide for additional staffing and beds. That investment continues.

The University Hospital Limerick budget has increased by nearly 60% in the lifetime of this Government. It has gone up from a budget of €265 million to now €423 million. Critically, investment in all of the hospitals of the mid-west region has increased by nearly the same amount, by 58%, an additional over €200 million. The mid-west region needs additional bed capacity and we are looking at all ways and means to deliver new beds into the region. Some 160 beds have been delivered to date in the lifetime of this Government.

Critically, 208 additional beds are under construction at UHL. The first 96-bed block will be completed by quarter 2 of next year and the second 96-bed block is due for completion in 2027. A 16-bed rapid build unit will be completed and operational this year. Some 198 beds are committed through the Acute Hospital Inpatient Bed Capacity Expansion Plan 2024-2031 which I published over the summer. This includes, on top of the bed I have just covered for University Hospital Limerick, an additional 84 new beds for UHL, an additional 24 new beds for Nenagh Hospital, an additional 48 new beds for Ennis Hospital and an additional 42 new beds at St. John's Hospital.

How does this all add up critically for the region and for the people of the mid-west? When this Government was elected in 2020, there were just under 700 hospital beds in the mid-west. We are adding 566 hospital beds to that, which is an increase in hospital beds of 80% for the mid-west. It is much needed and will be put to very important use. These 566 additional beds are the equivalent to one additional large hospital - the ones we call model 4 hospitals - and a smaller model 2 or model 3 hospital.

When this Government came into office, the mid-west had the lowest level of hospital beds per population of any of the six regions. Between the beds that we are adding and the ones that have already been added, the mid-west will have the second highest level of beds per capita of the six regions. We are not stopping there.

As Deputies will be aware, I have also asked our healthcare regulator, HIQA, to consider the case for a second emergency department in the region. In addition to that, a site has been identified for the Limerick surgical hub at Scoil Carmel. When it is fully operational, it will be able to provide an extra 4,000 extra day-case procedures, 6,000 extra minor operations, and more than 18,000 outpatient consultations each year.

We are, of course, investing in the workforce to support all of this. In UHL alone, the workforce has risen by nearly 1,200 healthcare workers in the lifetime of this Government. That is a 41% increase, bringing the workforce from 2,800 to just in excess of 4,000 healthcare professionals. It includes more than 170 additional doctors, more than 50 additional consultants, more than 400 additional nurses and midwives, as well as 120 health and social care professionals.

While I appreciate that we will quite rightly be focusing on the challenges in the mid-west today around urgent and emergency care, I want to take a moment to mention the other area of scheduled hospital care - where people in the mid-west are referred to see a hospital consultant for a scope or for surgery - and to acknowledge the work of our healthcare professionals in this area in the mid-west. We do not talk about this much because we are obviously focused on the challenges but I very much want to acknowledge every doctor, nurse, therapist and all of the non-clinical healthcare workers we have, and here are just some of the highlights.

Three years ago, the average waiting time for an outpatient appointment in the mid-west, from the time one's GP refers one in to see a consultant, was 17 months. The average waiting time now is less than six months. This means that we are well on our way to our agreed Sláintecare target. On inpatient care, the average waiting time has fallen from nearly eight months to five months now.

For scopes, the average waiting time has fallen from more than ten months to 3.4 months. We have some way to go. We are all signed up to the Sláintecare targets of ten to 12 weeks, but reducing the waiting time from 17 months to less than six months is a huge achievement by our healthcare professionals. I thank all of them for their work in making that happen for the people of the mid-west.

More capacity is needed. We also need to see improved work practices, as outlined clearly in the HSE review undertaken by Ms Grace Rothwell, Dr. Fergal Hickey and Ms Orla Kavanagh. The HSE review identified a range of work practices that need to be changed in University Hospital Limerick to improve patient flow and, ultimately, deal with the overcrowding of the emergency department. HIQA has also pointed out that work practice reforms are needed. In its latest report into UHL, HIQA noted that progress is being made but far more is required. The report by former Chief Justice Frank Clarke highlighted capacity constraints and a number of factors that contributed to the delayed treatment and tragic death of Aoife Johnston. In his report, Mr. Justice Clarke highlighted unclear protocols, ad hoc systems, poor internal communication and a failure to deploy the escalation protocol. His report also contained a number of recommendations.

The HSE's chief clinical officer, Dr. Colm Henry, is setting up a structure to oversee the immediate implementation of all the recommendations of the Clarke report. A new chief executive over acute and older persons, Mr. Ian Carter, has been appointed along with a new regional clinical director, Dr. Catherine Peters, and, as the committee will know, Ms Sandra Broderick, who is here with us today, started in her role as regional executive officer earlier than planned, as part of the HSE's plans to reform. Many consultants, doctors, nurses, health and social care professionals and many others working at the hospital recognise that work practice changes are needed and are supportive of those changes.

My thoughts remain very firmly with the Johnston family. Carol and James and Aoife's wider family have suffered the unimaginable loss of their beloved daughter Aoife. It is devastating to lose a child. The fraught circumstances in which Carol and James Johnston watched their daughter deteriorate at UHL before she succumbed to sepsis compounded their nightmare. As former Chief Justice Clarke said in his report:

To lose a child in the fraught and traumatic circumstances of Aoife's death is beyond understanding. To be present and feel powerless is unimaginable.

An unprecedented increase in healthcare capacity must be met with urgent reforms in how care is delivered to the people of the mid-west. A united approach and shared vision between the HSE, the administrative and clinical leadership at UHL and the Government will deliver the improved access to high-quality urgent and emergency care the people of the mid-west must have.

I welcome the Minister and his colleagues and thank them for coming before the committee. The subject matter before us has gained a lot of attention, tragically in some cases, and I welcome the Minister's indications as to the developments that are taking place in the region. They are not before time but they are still welcome. The emphasis now has to be on making them happen and making the various targets come within reach of the people such that the people will know that help is at hand and that the system is looking after them.

Public confidence in the system is very important. When someone is referred to hospital for whatever reason, they are in the hands of the hospital or hospitals, as the case may be, and the health services. Small things may in themselves seem to be of little importance in the make-up of the general package that is called into play in such circumstances, but they all count. They all culminate in the delivery of the service to the general public that the general public have a right to aspire to, get and expect at all times. It is unfortunate that things that should have happened did not happen, but "unfortunate" is of very little consolation to the victims and their families. The Minister noted, although it goes without saying, that we have to be keenly aware of the hurt in the individual cases where something happened that should not have happened. It is absolutely essential that we have a root-and-branch examination, without blaming anybody in the aftermath but making sure we will not have the revisit these scenes, and it is possible to do that. What we have learned, albeit tragically in some cases, should not allow us to downgrade the entire system. We have to recover from it and try to determine not only that these unfortunate outcomes will not happen again but that we will do everything we can to prevent them happening again.

I am sure everyone around this table has dealt with tragic cases that should never have happened and that it was well within the capacity of the services to avert. Sepsis is one example that has arisen regularly and, unfortunately, it is still rampant. I recall at a meeting such as this one a few years ago being told sepsis was very rare nowadays, but that was wrong information and I knew it was wrong. It suited the occasion for somebody to say it is very rare nowadays, but it is not. In maternity hospitals, for example, where pregnant women's blood pressure is fluctuating and so on, it is a distinct possibility but it is easily averted provided the right decisions are taken by the appropriate people at the right time. Sepsis happens quickly, and the point of return comes very quickly. It is no use saying after the fact that if we had started ten minutes earlier and addressed the issue, that would have resolved it. That is not the case. Sepsis has to be identified and dealt with very quickly. We must ensure we alert all the services throughout the country to the fact there is such a problem as sepsis and that it is lethal. My grandfather on my mother's side died of a ruptured appendix many years ago. That is a small indication of what can happen, and it happened very quickly.

I welcome the proposals that are coming before us and I thank the Minister and his officials. I visited the hospital in Limerick some time ago. It has been common lately to build a hospital while the hospital is in full operation. That is difficult. It is a challenge for the staff of the hospital and the contractors who are doing the work as well. There are lessons to be learned, and I hope we learn them and put the knowledge we have gleaned to good use. Part and parcel of that is that we must reassure the public we have recognised the problems and are in a position to deal with them and that they will not happen again insofar as we can guarantee.

I have to go to another meeting now but I will be back.

I welcome the witnesses.

Who is the current manager of the hospital in Limerick?

He may have landed on the ground but we are here as an Oireachtas health committee to look at very serious problems, and of course the progress, in the mid-west region. Ms Kenna, Ms Conroy, and Ms Broderick are here. He should be here. The Minister also said in his opening statement that there was a new regional clinical director, Dr. Catherine Peters. Is she here?

With respect to the Minister, we arranged this meeting to discuss the mid-west region. Therefore, I would have expected the managers who are on the ground managing what is happening to be here to hear what we have to say but also to answer questions we might have. The Minister can answer some questions; I am sure others can as well. I am just making that point. I will move on from it.

It is a fair challenge. If we want to do another session at an appropriate time, we can do that. I asked the regional executive officer to be here. The invitation was to me. Had the invitation come to the clinical director, of course we could have done that. It is a fair challenge. However, the invite was not just to discuss UHL; it was to discuss the region. The person best suited to discuss the regional healthcare profession is the new regional executive officer.

I will come to Ms Broderick now with my second question. I thank the Minister.

When we triage patients in the health services generally, we use what is called the Manchester triage categories. My understanding is that there are five categories, 1 to 5, with 1 being the most urgent and 5 the least urgent. My understanding is that categories 1, 2, 3 are the main ones. Patients in categories 4 and 5 can be referred elsewhere, but 1, 2 and 3 are the main, urgent category patients. Is that a correct analysis?

I have that. Rather than getting into a row on which numbers are correct, whether it is the INMO numbers or those of the HSE, the figure at this point does not really matter to me but we know there was a high volume of patients on trolleys in Limerick again this and last week. Are those people who were on trolleys categories 1, 2 and 3 patients?

That is my point. Yet, here we are with high numbers again in Limerick compared to other regions. I make that point to come to the issue of how we move forward. I recognise the additional capacity mentioned by the Minister earlier. I recognise all the other outpatient work, the people who are treated or are seen and procedures which are carried out which do not get noticed or talked about in terms of the mid-west. However, we do have a particular problem in the emergency department. As we know in his report into the death of Aoife Johnston, the former Chief Justice, Mr. Justice Clarke mentioned and referenced a decision that was made to close emergency departments elsewhere and to essentially not have a centre of excellence in the mid-west that was fit for purpose which has led, in some part - maybe in a large part depending on how you like at it - to what is being happening in the hospital.

The Minister has commissioned a review, which, by the way, I looked for. I had called for a review; there is a review in place. I want to get clarity from the Minister because it is an important thing for the people in the mid-west to understand. Would he agree there is an unassailable argument now for a second emergency department in the region? When we ask what is the problem in Limerick, we can get 50 different answers. What is evident, even from what we have just heard here regarding last week, is that we seem to have more patients on trolleys on a regular basis. Even with the extra beds, that may not solve it. Does that demonstrate, in and off itself and all the other problems we have seen, that there is a deficit of emergency departments in the region that needs to be addressed? I ask the Minister to answer that from his perspective first.

There is clearly a case to be made for a second emergency department. It is why I have asked HIQA to conduct a review specifically looking at that question. The straight answer is that there is clearly an argument to be made. However, there is nuance to it which HIQA needs to look at. If we look at the amount of additional bed capacity we are adding that is already in and that is now in train, it is the equivalent of adding two new hospitals to the mid-west. However, speaking directly to the Deputy's point, with all of that, there is not a second emergency department coming. The mid-west is the only region of the six that has one emergency department. UHL stands out from most of the rest of the country because while there has been a very big increase in the number of people coming into our emergency departments, across the country there has been a really important reduction in the number of people on trolleys in the vast majority of our hospitals, although not in every hospital. UHL really stands out as having moved very rapidly in the opposite direction. There is clearly something different about UHL. It is entirely possible that-----

I will add to that because I did my own calculations on this and, as the Minister knows, I published a plan for the mid-west a number of months ago where I set out what I felt was needed, including a review, in advance of the review being put in place. As I said, I welcome the review. Does the Minister know what the population of the mid-west is?

It depends on how you look at it but it is somewhere between 400,000 and 500,000 people. It is a minimum of 400,000 up to 500,000, depending on the catchment area. If the mid-west region had two emergency departments, it would mean the population per emergency department would be 200,000. If we take, for example, the south west, it has four emergency departments with one emergency department for 185,000. I can go through all the other regions. On population alone, if there was a second emergency department, this would bring the region in line with other areas. I say that to the Minister in terms of the HIQA review. There is a question of whether the review is just looking at whether it is needed as opposed to where the location should be. I know there is a need for a clinical underpinning of it as well. I wanted to make that point.

I have one last question. I will be careful how I raise this because I do not comment on individuals as I do not think it is fair to do so. However, there is a report in The Irish Times today about a former manager of the hospital who was appointed to a new role as a new integrated healthcare area manager in the mid-west. There was a line in the article which troubled me. Will the Minister confirm this and then perhaps elaborate as to why this was the case? The articles states: "It is understood she was among a small group offered such posts outside of a public competition". First, will the Minister explain why that happened and why it was done outside of a public competition? Was past performance of any individual - not just of one individual but of any individual - who was offered these posts taken into account? The family of Aoife Johnston are far from happy with that; I put this to the Minister because I am aware of it. I will leave the remaining time for him to respond to that.

I thank the Deputy. I appreciate he is being careful but we have to be very careful about what we say here. There is a significant disciplinary process under way that is a matter of public record, against the person the Deputy has discussed. These are highly legalistic processes, therefore we have to be very careful not to prejudice anything that would come out of that. It would not be wise for me to speak about past performance because one could convey that this is prejudicing disciplinary proceedings. I can say the disciplinary proceedings, which are now against six people in UHL, represent the signal biggest move in terms of accountability in the 20 years the HSE has existed. I am not going to comment on past performance if the Deputy does not mind.

On the second point, there is a redeployment of CHO leadership and hospital group leadership.

As the Deputy is aware, we are taking out several layers of senior management in the HSE, including CHO leadership and hospital group managers, and we have moved to a much flatter and smaller structure comprising the six regional executive officers. As part of that redeployment, not just in the mid-west but across the country, CHO leaders-----

Deputy David Cullinane: My time is up. I just want clarity on one issue and I will-----

What I am hearing from the Minister is a redeployment of certain posts. This is being covered in the media and I have a responsibility to provide factual information when I am asked, which I want to provide. There are families out there who have suffered because of problems in the hospital. I am not apportioning blame but it is difficult for them to read that there was a small group offered such posts outside of a public competition. Was the Minister aware that those posts were offered outside of public competition? Does he think that was the wise thing to do, given the circumstances? Why was that done?

I believe that a redeployment of the senior management within the move to the six regions is a reasonable thing to do. There was public competition, quite rightly, for the six regional executive officer, REO, posts. Regarding the mid-west, I want us to be really careful here. As of this moment, no findings have been made against anyone in UHL in regard to the tragic death of Aoife so I want to keep these issues completely separate and I know Deputy Cullinane will too.

I welcome the Minister and his team. The Minister has long heard me say that the 2009 decision to close 24-hour accident and emergency care in Ennis, Nenagh and St.John's was absolutely woeful for the mid-west region in which I live, and for County Clare, which I represent. It was absolutely woeful and has led to really poor health outcomes for many people, including death for some families. The perpetuation of this centre of excellence notion, both in the world of politics and by some in health leadership roles, is downright insulting to people in the region who face those woeful health outcomes. I want to acknowledge the Minister's efforts since he took office in 2020 and those of some of the people around him. They are trying their best after a decade of a hollowing-out of the health system and not investing in it. They are trying their best and there are improvements being made, which I acknowledge. It is the 2009 decision that I am hugely critical of and the whole rhetoric around that has to change. Ireland has to fess up and admit this was a huge failing on the part of the Government, the body politic and the health leadership in 2009.

When my mother began nursing in UHL, which was then called Limerick Regional Hospital, in the 1980s the population being served was 300,000 and there were five emergency departments in the wider region. These days, there are 500,000 people all being funnelled through one accident and emergency system. That contrasts so sharply with Dublin, where there are 1 million people with access to eight emergency departments.

I have a number of questions and will begin with Aoife Johnston, Lord have mercy on her. We all saw the "Prime Time" special programme last week. Mr. Justice Frank Clarke unequivocally stated that the death of Aoife Johnston at University Hospital Limerick in December 2022 was "almost certainly unavoidable". On this basis, and in accordance with the demand of Aoife's bereaved parents, Carol and James, will the Minister be setting up a statutory inquiry into her death? Given that there were huge systematic failures, will a State apology be offered?

Let me answer this question carefully. If the Cathaoirleach wants to stop the clock for Deputy Crowe, he should feel free to do so because this is a matter for all of us. I will try to make a few points on this. I have met Carol and James. It was heartbreaking. Aoife was 16. My oldest kid got his junior certificate results yesterday. He is 15. I cannot begin to imagine what they have gone through and what they are continuing to go through. My promise and that of Bernard Gloster is that we are going to put Carol and James and Aoife's family at the centre of anything that we do. That is our starting point and that will be our end point.

In terms of an apology, Bernard has apologised, I have apologised and I know UHL has apologised and quite rightly. If Carol and James want a more public apology, I cannot see any issue with that if it would help, be it from me, the Taoiseach or whoever else it may be. Through their solicitor, the Johnstons reached out to the Taoiseach and I yesterday. I have publicly stated on several occasions that I was very happy to meet them. Their solicitor wrote to me and the Taoiseach yesterday to suggest that we have that meeting. In the first instance, what I want to do, as do the Taoiseach and Bernard Gloster, is sit down and listen directly to what Carol and James want.

I am very conscious of the fact that the report by Mr. Justice Clarke makes it very clear that there is conflicting evidence, that there were people who came in to give him evidence and there were serious discrepancies in what people said. If that was my child, I would want to know who was telling the truth. They are absolutely correct to ask for a factual account of what happened. Mr. Justice Clarke, to the greatest extent he could, took the evidence and laid out the conflicts in a helpful way. He was essentially showing us the conflict; he was not trying to simply pass it off. He was making the conflict very clear. I want to talk to Aoife's mum and dad about that and about the best way to get the truth. They have a right to the truth and significantly conflicting evidence does not get that for them. They also want accountability and they are right to want that. On the back of the report from Mr. Justice Clarke, the chief executive has launched the biggest process in pursuit of accountability in the 20-year history of the HSE. Six disciplinary processes have been initiated and several of them are at the highest level. Several individuals, as the committee will be aware, are on administrative leave.

That brings us to the question of where we go from here. Statutory inquiries do not always do what we want them to do and what grieving parents and others want them to do. I had one on the Grace case on my desk for several years. That was commissioned as a statutory inquiry in 2016 and it is now with the Minister, Deputy O'Gorman. The first report into the first phase of that work will be published shortly. There are other examples. The statutory inquiry investigating the events around Sergeant Maurice McCabe was launched but, on the back of that, any issue with the pursuit of accountability had to go back to the employer. Ultimately, the employer is tasked with accountability-----

Thanks Chair and Deputy. If we were to launch a statutory inquiry, one of the questions we would have to be able to answer is whether the legal teams of those currently under investigation by their employer will say that those investigations have to stop. They could say that they have to be paused and they could be paused for two, four, eight or ten years. I hear the family with all of my heart and we have to do right by the family. The only thing I am saying is that statutory inquiries do not necessarily do what we all want them to do.

I am delighted to have received the letter last night. The Taoiseach and I will meet Carol and James and will have this conversation with them. We will tease it all out but I want to assure the committee that the only thing that matters to me in this is Aoife and her family.

I thank the Minister. It is no secret that an election is close. My worry is that when we get into that cycle and the formation of government that comes after it, the body politic will potentially get stretched out for four or five months, which would do no good to this process. I would love if the Minister and his officials could expedite the ask of the Johnston family to initiate a statutory inquiry. There is some value to the work undertaken by Mr. Justice Clarke, but it does not get into the responsibility. There needs to be significant follow-ups to this, but I do not see that yet in the Clarke report.

I join others in saying that a feature of the report by Mr. Justice Clarke was that on the night Aoife Johnston died it was not clear who was in charge of UHL. That is a quote from his report. It is pretty woeful that the management - the person in charge - namely, Ian Carter, is not here either. I accept that he has recently taken up the post, but I have been saying for two years that the management team in UHL moved out of the hospital campus, 2 km up the road to a business park, which was ludicrous. He is not here either today. He should be here, even if he took up the post this morning. That is irrelevant. He is now the custodian at the helm of the hospital. In my former life as a teacher it would be unheard of to have the principal of the school somewhere down the road in an office block, remote from the school. We have heard why Mr. Carter is not here but I do not accept it. The excuse he has given is not valid. When will the management team in UHL move back to the hospital campus?

I understand. I have already accepted what Deputy Cullinane said. It is a fair challenge, but if I might challenge back slightly: he was not invited. I was invited, and I have come with the regional executive officer, who was not invited. I also come with three assistant secretaries who were not invited. If the committee was that keen on speaking to Ian Carter, respectfully, it should have invited him here. The committee did not invite him. Nonetheless, it is a very fair challenge and it would be useful to hear from Ian. Given that he has just started, his evidence would probably be more useful to the committee after he has at least a few weeks to get a sense of it himself.

The office block has been closed. I can tell Deputy Crowe that Ian has set up residence in the hospital. He is a formidable gentleman and manager. The office block should never have been opened. The management should have been on the site all the time. The block is now being turned into an outpatient department.

That is a positive development. I will follow the lines of Deputy Cullinane's questioning, and I will be careful. He has asked most of the questions. While the Minister responded, I was struck by the fact that his counterpart, the Minister, Deputy McEntee, and her Department also have people on administrative leave in An Garda Síochána, but they do not move sideways or get promoted. When they are on administrative leave, there is a process under way, and that is where people stay until the process has ended. They draw their salary and remain on the payroll but they do not move within the HR structure. Why are individuals in that holding pen, as it were, allowed to move laterally and vertically in terms of promotion?

I thank the Deputy very much. The first and simple answer is because the role does not exist any more. The role of hospital group chief executive does not exist. The role of CHO chief executive does not exist. This is not the same as someone being on administrative leave and simply moving from one permanent post to another. The role that the individual occupied is gone.

The second point is that while I am not a contract lawyer, I imagine that any move in the middle of a disciplinary process, other than what would be taking place, could be argued as prejudicial to the investigation.

I fully hear the Minister, but there is no garda on administrative leave being promoted to the rank of chief superintendent, so the whole thing does not make sense. However, I hear the Minister. I know Ministers do not get involved in HR areas like this, but someone needs to advise on this and slow it all down. A process is under way and we must allow it space. We cannot prejudice the outcome of it. It is unusual that people can be promoted and go elsewhere while there is an inquiry relating to their performance in the workplace.

I thank the Deputy. I will make two quick points in response. One is that it is not a promotion. It is moving to what arguably would be seen as a smaller span of control, so I would not characterise it as a promotion. The promotion would be to Sandra Broderick's role, which is the regional executive officer role.

The second point I would make is that the Deputy should not underestimate the power of contract law in this country. I am only saying this because it is a matter of public record. The clinical director in the hospital has been placed on administrative leave, and he has sought recourse from the High Court to stop the chief executive from placing him on administrative leave. The burden falls strongly in favour of the employee. I am not saying that is wrong.

I will hopefully come back in later, but will ask the Minister a final question. I have long been speaking about Ennis General Hospital and elective surgeries being suspended there for ten weeks. Surgery took place on perhaps four days in ten weeks. The theatre nurses, who are highly skilled, were redeployed to other functions in general medical wards. This is not personal, but the consultants are on public-only contracts and when operations are not taking place they do not have a private list to go to. My understanding is that they are currently on leave. Again, that is such a valuable skill set that is lying idle somewhere. It is so wrong. I know this protocol came in to ease pressure in UHL, but it has been disproportionate in the mid-west. Nenagh Hospital is up and running but we do not know where we are with Ennis, which is hit and miss. Could the Minister clarify the situation and outline the possible plans to expand hours in Ennis from next week onwards? Could he give a small bit of detail on that? I will come in with further questions later.

The Deputy is aware of the huge volume of unscheduled care attendances in UHL. Ennis provides a release valve in terms of decompressing the main site. That is why we have seen stops and starts with the scheduled care. We do continue with scheduled care when we can and when that is permitted. I am not aware of any contract-holder surgeon who is off work when we are not doing operations in Ennis, so I will have to go and check that out.

They may be in Dooradoyle. I will come back to the Deputy on that, if that is okay.

In terms of the redeployment of nurses, it is only right that we redeploy them to look after patients. Staff are redeployed right across the board, whether it is nurses or anyone else for that matter, as we must look after the patients who are presenting to us.

Deputy Crowe is absolutely right about the expansion of the medical assessment unit, MAU, hours. They will be extended from next week onwards.

I welcome the witnesses to the session. I want to stick with the issue of accountability. The apparent lack of accountability across senior levels within the public service and the Civil Service is something that drives the public mad. We see on a regular basis that there are rarely consequences involved when things go wrong for the senior people who may not have been doing their job properly or who may have failed in their responsibilities. I make those points in a general sense; I am not talking about UHL. It is a major issue. It is particularly acute within the health service.

This issue was discussed at some length during the deliberations of the committee that came up with the Sláintecare plan. A very strong recommendation within Sláintecare was that there needed to be legislation to provide for accountability at administrative and clinical level within the health service. That was endorsed right across the board by all parties involved in that committee.

It is quite regrettable that this Government or that which preceded it did not move to introduce such legislation. I recall the first meeting of this committee that Mr. Bernard Gloster attended after being appointed. I put that question to him in respect of the regional executive officers and his response was that while the Government was not planning legislation, it was his view that the contracts being awarded were sufficiently strong. That is yet to be tested. I look forward to hearing further on that from Mr. Gloster at a later date. It is very regrettable that the Government failed to follow through on that recommendation. That leaves us in all kinds of complicated circumstances in different Departments and State agencies in the context of establishing accountability and people being seen to face the consequences when things go wrong. I do not know if the Minister wants to respond to the question about the failure to legislate for accountability.

The short answer is that I agree with the Deputy. I agree with the Sláintecare recommendation. I agree with her point when it comes to the health service and the wider public sector. It is something that should be considered in the next programme for Government, whoever may be putting that together. Again, I am not an employment lawyer, but I have learned more about it over the past few years. The burden on the employer or the balance of rights or whatever the appropriate way to describe it is does make accountability difficult. I agree with the Deputy's point.

I will make two follow-on points, one of which is that it is still possible. As we are seeing in UHL, there are now six disciplinary processes under way, but it is a very legalistic and slow process.

Yes, I could not agree more. The clinical director role does not do what most of us think it was meant to do, which is to performance manage. Obviously, we champion patient safety, but within that we must make sure the clinical teams within the organisations are operating to the best extent possible. There are some clinical directors who do that.

If that is the Minister's view, I suggest that he might give consideration to reinstating the reporting arrangements for clinical directors because they have essentially been abandoned. In the context of accountability and the management structure, the Minister spoke to us about Ms Broderick, Mr. Carter and Dr. Peters. What exactly is that structure?

I am the regional officer, and I report to Mr. Gloster who is the CEO of the organisation. On my executive management team in the mid-west, Mr. Ian Carter takes responsibility for all acute services with older person services, which is a really new governance line for the mid-west particularly. That includes our long-term care facilities, short-stay beds and home support integrated care programmes for older people teams. Ms Maria Bridgeman takes responsibility for all the other elements of the community services including mental health services right across the mid-west region. Dr. Catherine Peters is the regional clinical director, so she is responsible for patient safety, quality and all of the clinical-----

That is good. I thank Ms Broderick for that. The other two areas of accountability obviously relate to the two areas identified in Mr. Justice Frank Clarke's report, one of which was the completely inadequate capacity within the mid-west region in terms of emergency department, ED, capacity. That has to be a matter of political accountability. One does have to wonder about the original configuration arising out of the Horwath report in 2008. That report was very clear that UHL needed to get up to a level of over 600 beds before the three other EDs were closed. Six Ministers for Health later and that has not happened. We are still more than 100 beds short of what was recommended at that stage in 2008 and the population, of course, has grown very considerably. All Ministers, including the current Minister, have to take responsibility for that. It was made very clear at the time of the reconfiguration, and we have had major problems in the period since then. Will the Minister-----

I thank the Deputy for that. I am more than happy to take responsibility, obviously, but in the interest of fairness, when I was appointed, there were approximately 400 beds in UHL. We have added 118. There are 16 more that are going to open this year, 96 more in quarter 2 of next year, another 96 after that - they are under construction - and a further 84. I am more than happy to take responsibility for things but in this case, on my watch, we will have moved UHL from approximately 400 beds, I have not got the number, but it is close to 700 beds.

The recommendation was that the other three EDs should not close until we had reached a level beyond 600 beds in UHL. That has been the problem, notwithstanding recent improvements as regards the number of beds. That is a fundamental point. Those three emergency departments should not have been closed. It is quite clear that was the original intention. I have been raising the issue for more than two years now about the need for a second ED for a level 3 hospital in the mid-west. The Minister said he asked HIQA to examine this in recent times. Why is he only saying that now, given that two and a half years ago HIQA was very clear about the nature of the problem in a report on the unannounced inspection of the emergency department in UHL? It stated two and a half years ago that the absence of a model 3 hospital in the region significantly impacted the effective workings of Limerick's ED. Why is it that the Minister has not taken action on that view from HIQA? He would have received that report two and a half years ago.

That is exactly the way I was characterising the Deputy's question. It is because two and a half years ago, we were in the middle of a massive expansion of capacity in the mid-west, not just in UHL and the other regional hospitals but in the community. We have opened five primary care centres and a lot more. This time last year, the emergency department situation in UHL was moving in the right direction and up until this year, it looked like the huge additional capacity that was being invested in the community sector and in the acute sector in the mid-west was working. We have seen this year that things moved in the opposite direction, and there was a significant increase in the numbers on trolleys. When we saw that, it was the trigger for asking HIQA to report back.

There is a serious issue of geography here. Does the Minister think it is acceptable that someone in need of medical treatment in, for example, Loop Head in County Clare or in Latteragh in County Tipperary, must not only drive past a hospital, but will also have a greater chance of dying if they have a major medical emergency because UHL is so overstretched and overcrowded? There is a geography issue there in the context of the distance that must be travelled. This is further grounds for designating one of the other hospitals as a level 3. Does the Minister accept that?

There is definitely a distance and geography issue. I spend as much time as I can in west Clare and I know from my time there and talking to people in Ennis hospital that there is real concern at the distance. Deputy Shortall very fairly referred to HIQA. Its view was that the scale of Ennis hospital meant that it could not safely support an emergency department. That is exactly why I have asked HIQA to do this work. I do not want to prejudge its work but it may not come back to say it should be in Ennis or Nenagh or St. John's.

We must first ensure that as many people as possible can be treated in Ennis. It has a minor injury unit that is second to none. We have a medical assessment unit there that is going from strength to strength. We have funded additional National Ambulance Service services which are more advanced and have more advanced paramedics. We are also looking at helicopter coverage. I fully agree with Deputy Shortall's point for the people of County Clare, particularly north and west Clare. There is a real concern and we do have a geographical challenge, there is no question about that. What we are looking to do now is to say that we can provide more and better care in Ennis and better responsive ambulance and helicopter services while we look at the bigger question of a second emergency department.

I welcome the Minister and the witnesses. Returning to the HIQA report, when is that report due? I believe that a city centre or other central location where nurses' stations can see the patients from where they are situated might be worth looking at that. That is my first question.

With regard to consultant contracts, I understand some consultants work on a part-time basis because they have other responsibilities. Is UHL going to look towards 24-7 consultant contracts, similar to what they have in America, where people are on eight-hour shifts, such that there are consultants there constantly? It certainly might help the situation if there were consultants, triage staff and protocols there.

I thank the Senator. I am expecting a preliminary briefing on the HIQA report in February and the final report will be in May.

I applaud the Deputy's question on consultant contracts and 24-7 on-site rostered consultant presence in our hospitals with emergency departments. The new consultant contract doubles the normal rostered times, which was a really important move. Our view was that we could not go further than that. We have succeeded in having a lot of interest internationally in the new consultant contract. Since this Government came in, our consultant numbers have gone up from approximately 3,200 to approximately 4,500. There is a lot of interest around the world and many Irish trained doctors are coming home. I think we got the balance right.

Had we gone to a normal roster on a 24-7 basis, we would not have had the level of interest in the contract that we need. In the long term, however, I am 100% of the view that busy hospitals with emergency departments should have regular rostered consultant 24-7 presence, as is the case in hospitals I visit around the world. When I talk to those hospitals about the rostering in Ireland, in some cases they are very surprised to hear that. I believe we should move there. We are not about to re-open the consultant contract. At least, this Government is not about to do so. I do not think there is any appetite to reopen the consultant contract now. It is a good contract. It was hard-negotiated and hard won. It is doing the business but, within that, we have to maximise the normal rostered on-site hours. As I said, it will double the normal rostering.

In Limerick, there is going to be a new surgical hub and the site has been identified, as the Minister rightly said. I know an elective hospital was ruled out. I firmly believe Barrington's hospital is going to be vacated at the end of the year. Should we look at that as a temporary stop-gap? The building for the surgical hub has to be knocked down, rebuilt and the whole lot. That is going to take time. Should Barrington's hospital be used as a temporary location while the new surgical hub is being built? Should a surgical elective hospital be back on the table in terms of a model 3 unit?

We looked at Barrington's hospital but the operational view of the HSE was that the quickest way to do it was to proceed with the identified site rather than trying to split teams between setting up a temporary solution and the permanent facility that we want.

On the elective hospitals, I hear loud and clear the people in Limerick loud and clear when they say there is an elective hospital in Cork, another in Galway and two in Dublin and they should have one as well. The elective hospitals are national hospitals. They happen to be located in those four areas but doctors, surgeons and proceduralists in the mid-west, in Limerick, will have full access and full referring rights to the regional hospitals.

Following up on Deputy Cathal Crowe's question on an inquiry, the Minister said he is going to meet the family of Aoife Johnston. Does the Minister think there will be another inquiry in terms of an independent report? Much like Deputy Crowe, the line in Mr. Justice Clarke's report that frightened me was that there seemed to be nobody in charge. That really was the line that frightened me. I meet people, especially those in the older age category, who are afraid to go to the hospital. People are getting the wrong message. Is there going to be a statutory inquiry?

I am not ruling anything in or out. I want to meet Aoife's mum and dad and have this conversation with them. When it comes to the responsibilities, however, all of our responsibilities and the responsibility of the HSE to learn patient safety lessons and implement them, we do not need a statutory inquiry for that piece. I know there are really serious and heartfelt questions Aoife's family have, which are separate from that, regarding what happened and who is responsible. Critically, on the Deputy's question as to whether we are taking everything that can be learnt clinically from a patient safety perspective and applying that, yes, we are doing that. A statutory inquiry will not help with that. They tend to take years, as the Deputy will be aware. We would certainly not be waiting. We are already acting. The chief clinical officer, Colm Henry, has already set up a team and Sandra Broderick is very involved in this, as are the team in UHL and Rachel Kenna, who is head of the national patient safety office and the chief nursing officer at a national level, in terms of sepsis protocols and other patient safety issues. There is a whole team acting to implement everything that can be implemented. A statutory inquiry would not help. It might not hinder things but it would not be necessary for the clinical patient safety response.

There are many units that operate at 100% in UHL and I want to pay tribute to the staff in every department, be the emergency department, oncology, the heart unit or the stroke unit.

It is a pity that Limerick is always in the news for it accident and emergency unit, the bad news story that comes out of that and that people are sometimes frightened to go there. People want to have a safe patient experience and there is the safety of the staff as well.

On the oncology unit, are there any plans to add that to the national centre? They are at such an advanced stage there. Is there any expansion with regard to that?

Regarding the HIQA report, I know that St. John's Hospital had a report I know the Minister is aware of and has on his desk, which is to do with replacement beds. These are 120 extra beds to replace the already existing beds in the hospital, so as to expand St. John's Hospital where more procedures could be carried out. The Minister might comment on that as well.

I thank the Senator for that. We are going to get her the beds number. We had some very good news for St. John's. I am just going to find it now. In the new bed plan, we have committed an additional 57 beds to St. John's. I have been in the hospital several times. It has an amazing team that put a very strong case together.

The Senator will be aware that 15 beds have been delivered and in the new plan, we have committed to an additional 42 on top of that. It will be a very substantial increase for St. John's and much deserved. It has an incredible team. It has been my great pleasure to be in with them a few times.

On the cancer infrastructure and services, I have a lot of detail here. What I might do is ask the officials to send the Senator a note.

There is more here than I can cover. I will give the Senator one or two highlights, if I may. The day unit in UHL has been a big focus with regard to cancer care infrastructure. UHL has prepared and submitted a capital project proposal to move the administrative and clerical meeting spaces to a separate building and to convert those spaces to clinical spaces to increase capacity. That is something that is being looked at the moment. I think that would make a difference.

I have various other notes here that I can go through or, if the Senator prefers, I can have a detailed note sent to her.

I will not delay the Minister but obviously, Limerick is one of the eight cancer centres so it is hugely important in terms of our national cancer services. The Minister announced very significant funding for cancer services in the budget over the last number of days. To give the Senator a sense, under the national cancer strategy we have invested over €8 million in funding, and €3.8 million annual funding and €4.5 million in once-off funding are very significant numbers with increases in staff. There are over 40 WTEs in Limerick alone right across the spectrum. We can give the Senator a very detailed note but there is a lot of really significant work going on in cancer services in Limerick, aligned with the approach to cancer services nationally.

I will get the Senator a note on that. I cannot be sure but I think I may have misspoken. I think I might have been on radio or in the Oireachtas and I may have said quarter 1, when in fact it was quarter 2. That might simply be optimism bias on my part. If it was indeed quarter 1 and it has been moved to quarter 2, I will get the Senator a note on that and what the reasons for that would have been but I have a suspicion that I just misspoke previously.

First, I welcome the Minister and his delegation to the committee. As a Member of the Oireachtas representing the people of north Tipperary, I am very familiar with the problems and failures in the delivery of healthcare in the mid-west region. I was one of those representatives who continually went to the meetings, and after every meeting I left in frustration and anger because we were always painted the blue-skies picture. We were given misleading information. We were given objectives and targets that were unachievable and never met. I am glad that, at this stage, UHL is front and centre of the political debate and the consciousness of the public because we needed that to get changes and the proper service we require.

First, I welcome the changes to the governance structure. I welcome the initiatives to improve and reform procedures and practices at UHL and already, I as a public representative, from my communications with management, staff and patients, can see a difference. Already I can see there is more openness and transparency. My message, as a public representative, is that we are there in the first instance to look after the interests of the patient. Failures just have to be addressed and whatever needs to be done to improve the services must be done. I, as a public representative, am saying to the Minister that for whatever actions need to be taken and need to be implemented, he has to have the full support of all public representatives in doing that. We have to act in the best interests of the people we represent and who need healthcare. All corrective measures must be implemented as quickly as possible.

I have been following it as I was on the old health board for years but we have all seen massive investment in both personnel and resources in UHL. All of us, even laypeople, could see we were not getting a return on the investment being made. There was no improvement in the outcomes. I welcome the fact that these measures are now being taken but unfortunately they should have been taken years ago.

On Nenagh, which is obviously in my constituency, is a hugely important element and a critical component of healthcare delivery in the mid-west region. My priority has always been to protect Nenagh and its future and to have as many services delivered there for the people as locally as possible. We have an injury unit at Nenagh and I believe it is not being maximised to its full potential. I would say to the Minister and Ms Broderick that with regard to the injury unit, we can do a lot more to improve and extend the services there and have more people go directly to it.

On the medical assessment unit in Nenagh, we need to sit around the table with the professionals in the hospital, including the nursing staff, have dialogue with them, seek their co-operation and discuss it with them. Nobody expects that the medical assessment unit can have extended hours with the same level of staff. My understanding is that the Minister has already committed to additional staff and that recruitment processes are under way. Again, when you have somebody passing Nenagh and going in to Limerick which is already overcrowded, it is completely logical to make sure that GPs use the medical assessment unit. I ask that the Minister would meet with the GPs of our region, encourage them and explain to them what services the unit offers, and to listen to the GPs and see why it is they are not sending more patients to the medical assessment unit. They obviously have valid reasons, and whatever reasons they have need to be discussed, thrashed out and we need to take their views into account.

As for day-care surgery, I note there is a commitment to a new surgical unit in Limerick. That, I have to say, is probably necessary but what we need to do is to again ensure we are maximising the potential of the day surgery unit in Nenagh. At the moment, it is not being utilised to its maximum. There are days when there are slots available that are not being taken up.

On the new community nursing home in Nenagh, when was the contract signed for that and what is the duration of the contract? As we know, it was originally designed for the transfer of patients from St. Conlon's. How long is that temporary measure going to be in place?

On the 24-bed acute bed complement for Nenagh, has the actual location in the hospital been identified for that?

Has the design work on it started? What is the timescale for delivery?

My final question is for Ms Broderick. Is the HSE committed to the purchase of Mount Carmel, Roscrea? The Minister gave me a commitment on this previously. How advanced is the purchase? When is it expected to be completed?

I will give some very quick answers and then ask Ms Broderick to outline some of the operational details. As the Deputy stated, there has been a big investment in the injury and medical assessment units. The hours have been extended. The Deputy and I discussed this in the Dáil earlier this week or maybe last week. We need the facility to be fully utilised. I have no doubt that Ms Broderick and the HSE team can and will engage with GPs and other referral pathway representatives to ensure we are utilising it fully. There are ongoing discussions with the unions on rostering, and we need these resolved in order that we can expand access again.

The commitment from me on the community nursing unit stands. The current measure is a temporary measure until the first 96-bed block is open. When that is open, the unit can revert to being an absolutely beautiful community nursing unit for the local area. I will get the Deputy a note on the 24-bed block for Nenagh. I do not have the information here but will ask my officials to send the Deputy a note on the timing. I will now ask Ms Broderick to contribute on any or all of those issues.

On Mount Carmel, I sent the Deputy some correspondence indicating we are absolutely committed to completing the purchase of Mount Carmel. We have completed the due diligence but just need to discuss some of that with the proprietors now. We are 100% committed to making sure that we acquire Mount Carmel nursing home. It will probably be in the next number of weeks. That is the intention but there are just a couple of aspects we need to discuss with the proprietors. That is definitely ongoing.

The second point relates to Nenagh. Like the Minister, we are absolutely committed to handing it back. However, there are 27 patients in the facility right now and another four are due to be transferred from UHL. Everyone would welcome the fact that this means 31 people who would otherwise be in a bed in UHL at this point. The facility is doing what it was intended to do and patients are being admitted to it and discharged from it after they have received rehabilitation. I was there recently and many of the patients there told me they had received a really good service there and ongoing rehabilitation that ensured that they would not need to go into long-term care. All of us would welcome any older person not having to go into long-term care prematurely because he or she has no access to rehabilitation. That is an important element of what we are doing in Nenagh.

I thank the Cathaoirleach for giving me the opportunity to address the witnesses. I thank the witnesses for their opening statements.

I want to refer to a few points that have already been made. The Minister began by referring to the additional bed capacity required for the mid-west region. He pointed to the fact that the mid-west has the lowest number of beds per population among the six regions. This is the rationale for the additional bed capacity that is called for. The frustration in the likes of County Clare is that we do not have an alternative or another emergency department in the county. We are the only county in the whole of Munster that does not. There are many indications in this regard to be considered. The Minister said there are nuances concerning the additional emergency department. Could he give further details on those? The HIQA report, as mentioned by Deputy Shortall, points to the fact that there is an additional emergency department needed, and that this was the only way we would address the overcrowding experienced in the region.

The Minister said the emergency department was going in a different direction last year. Maybe he could return to that point. I understand surgical capacity in UHL was triggered every day of 2023. Is there conflicting information? What is it that the Minister said was going in the right direction when it came to UHL specifically?

I might as well return to the subject of poor Aoife Johnston. The Minister mentioned he is going to have a meeting with her parents, which is great to hear. They have been clear so far and they need a statutory inquiry. The Minister has pointed to the length of time not being helpful. When it comes to this significant loss, to which the Minister alluded, time is not an issue for the family. Obviously, they would want answers as quickly as possible to help them through the grieving process, but, in the greater scheme of things, it is a matter of them achieving accountability and, in effect, being able to point to who is at fault. When you have experienced the kind of loss in question, it is an injustice and you want somebody to be held accountable for it. As we know, the grief will never go away. It is lifelong for the family. Bearing that in mind, the Minister can appreciate that time is possibly not a factor for the family. Is the meeting set up or is it something the Minister hopes to achieve in the coming days?

An elderly man was left waiting over two and a half hours for an ambulance in west Clare. There was a great deal of backwards and forwards and eventually the decision was made to airlift the individual. Why was this decision not made earlier, and why was the man only provided with paracetamol during the period?

Last week, representatives of the INMO and SIPTU were before the health committee. Their message, which is that circumstances are not safe, was really concerning. The Minister has pointed to safer staffing levels but, with the pay and numbers and strategy brought into effect, I cannot help but point out the number of vacancies in UHL. Currently, there are 240.42 whole-time equivalent nursing vacancies in UHL. SIPTU, the time of the meeting, was able to provide information to me indicating that there were over 70-odd healthcare assistant vacancies also 70-odd support staff vacancies. Therefore, there are significant deficits across all grades. While we were happy to see the lifting of the embargo, what is now happening is affecting public confidence, even in respect of public representatives. If we are just to replace the language and give the same result at the end of the day, it will affect confidence and the belief in whether there is conviction on the part of the Government. What we have heard is that REOs are being put in a situation in which the one that shouts the loudest will get the most. Is that the situation we are facing? It was pointed out that we would be robbing Peter to pay Paul, which is ludicrous in a health system.

The representatives also pointed to the bureaucratic process in place whereby recruiters cannot even advertise posts that are to become vacant until the vacancy actually arises. The entire process to fill a vacancy takes about six months. I wanted to raise this with the witnesses directly and saw this meeting as an opportunity because, in many respects, the process is tying the hands of trying to bring about safe staffing levels, which is what we are saying is required. That is the space we need to be in.

I wish to refer to many of the announcements that have been made, including on the additional beds to be made available in the region, which will be the equivalent of a model 4 hospital and a model 3 hospital. With respect, we are not there yet. Nobody in County Clare will be jumping for joy, especially considering we have only had an additional 118 beds thus far. It has been stated that once everything is delivered and the investment is made, we will have the second highest level in the country. When will that be?

I am really happy that Senator Maria Byrne was able to talk about the differences in the timelines for delivery. The Minister said he might have misspoken, but I have got the timelines in responses. I have noticed a pattern in this regard. Each time I ask a question about the satellite haemodialysis unit coming to Ennis General Hospital, the timeline I am given changes.

The second 96-bed block that is to be delivered-----

Okay. Maybe they can come back. I will finish on the point that 2028 was the timeline I was given for the second 96-bed block; today the Minister has said 2027. I would like to stick with his timeline rather than the one I have received through a parliamentary question response. Will he explain why the dates keep changing? When will the 48 additional beds for Ennis be delivered? At a recent briefing we got from the UL Hospitals Group, that group said it is not sure where the satellite haemodialysis unit and 48 beds will go. It has not been logistically planned for.

There are a number of questions there. I am sorry for that but maybe the Minister will come back on as many as he can. I thank him and the Chair.

The Deputy has asked some new questions that are pertinent to patient safety in UHL. We might ask the Chair for a little indulgence in terms of the clock.

The claims being made about staff vacancies and patient safety are disputed by me, the Department, the chief nurse and the HSE. I have written to the unions and asked for a list of these 2,000 alleged vacant posts. We have not got it yet. If we get it, we will do a full audit of that. We take any such situation very seriously. The claim made of 240 vacant nursing posts in UHL is simply not true or correct. I will ask Ms Kenna to come in on this. There were claims made last year that there were several hundred vacant nursing posts in UHL and that they were not at safe staffing levels. Ms Kenna is the chief nurse, has led the deployment of safe staffing and is the head of patient safety. I asked her and the team to go immediately to UHL to check because we takes these claims seriously. I ask her to convey what she found.

I thank the Deputy for the questions and the opportunity to go through a site visit we did to UHL in the context of safe staffing. Safe staffing is not a head count or a ratio of nurses to patients. It is an evidence-based approach to determining safe nurse staffing levels in an acute environment and is based on patient need. The indicator we use is nursing hours required to look after certain groups of patients. The evidence behind it comes from hours of observational study in acute medical, surgical and emergency environments. It is a scientific approach.

We saw when we went to UHL that the funding was in place for complete implementation of phase 1 and 2 safe staffing in the appropriate areas. There are additional areas that sit outside safe staffing and use other tools, and additional staffing was applied to those as well, but we focused specifically on the scientific evidence we had for safe staffing. There were enough nursing hours for the care that was needed in UHL at that point in time. We found there were more nursing hours available in some areas and not enough in others. That is not a simple move-around translation; it requires a safe and structured approach to redeploy staff to areas to share nursing hours appropriately, achieve safe staffing and, therefore, get the desired outcomes. We commenced that process and have a list of actions with the staff in UHL. There is an ongoing structured process with them, supported by my team and by colleagues in the HSE, to ensure appropriate nursing hours in all designated areas are applied.

The second thing we found which is probably relevant is that some areas dealing with surge patients, that is patients coming from the emergency department, were not staffed with permanent staff. They were relying on agency staff and, as we all know, that is not a reliable or sustainable way to staff acute hospitals. When agency staff were not available, good decisions were being made about using the resource in the hospital at the time, but staff would be moved from one area to deal with surge patients and spread the care requirements, which can lead, across a hospital, to safe staffing not being felt or delivered. At the time of our visit, additional staffing resources were approved. My understanding is they have almost completed recruitment and there is a permanent staffing base for the surge areas, which is important.

In addition to that, UHL has the IT system behind safe staffing, so we can calculate and look at the nursing hours required in each ward area. If they are under or over nursing hours, that can be done daily and be visible to the staff. To support full implementation of that, we have commenced a training exercise with all ward managers and senior nursing staff in the hospital. That has progressed well. There is also a safe staffing co-ordinator post in the hospital and her or his job is to utilise the IT system and make sure the nursing hours requirement is applied appropriately throughout the hospital. If it is helpful, I can provide the Deputy with a more detailed note on the safe staffing and safe staffing application in the acute hospital environment. UHL has implemented phases 1 and 2.

The safe staffing framework allows for ongoing assessment. On an annual or biannual basis, you can reassess based on need and adjust staffing accordingly. That is in line with the budgeting process every year.

I commit to getting a note on haemodialysis. The following is relevant to all members and goes to the heart of this. The Deputy asked will it be a question of which region shouts the loudest. The region, quite rightly, that has had the biggest per capita increase in investment in healthcare in the time of this Government is the mid-west. The region that has had the biggest increase in beds per capita is the mid-west. The region that has had the biggest increase in healthcare staff, quite rightly, is the mid-west. The region that gets the greatest allocation in the 3,000 bed plan, quite rightly, is the mid-west. Ms Broderick can spare her shouting for operational matters in the mid-west because this Government has acknowledged - and I openly acknowledge it - there was under-resourcing in the mid-west relative to other regions. We are not just addressing that, as we must. By the time we finish, it will have the second highest number of hospital beds per capita of any region. The Deputy's question goes right to the heart of some of the problems in the mid-west and what we are doing about them.

The region with the highest trolley numbers consistently, every week and every day, is the mid-west. Whatever investment has gone in, it is still not enough.

I thank the Minister and his officials for coming in. I was not present at the start of the meeting because I was at an event in Farmleigh to celebrate visually impaired Paralympians that was arranged a number of weeks ago, but I have followed it online and need to put on the record that, at every opportunity that presented, I have raised UHL at this committee. There has been some public discourse to the contrary and I want to nail that. I think the Chair would confirm that as well.

I agree with Deputies Cullinane and Crowe that the new CEO, or whatever his title is, should have been here. Just because he was not invited, it is not a good enough reason not to be here. I think the Minister accepts that, because I have been following the meeting more or less since the beginning.

I also agree with my colleague, Deputy Durkan. He said public perception and confidence are important. We have a duty to do our very best to elicit public confidence. It can be difficult and challenging. It is important to acknowledge, as the Minister did, the work carried out by the clinicians and non-clinical staff throughout UHL and the group.

They do phenomenal work. I also want to put on record the great work done by the patient advocacy liaison service, PALS, in UHL. I have got phenomenal feedback on that good work. However, what I want to concentrate on today is the HIQA report. My first question for the Minister is simple. What learnings did he glean from Mr. Justice Clarke's report that then influenced the terms of reference? The terms of reference were delayed until after Mr. Justice Clarke reported. How did that report influence the terms of reference? Did it influence them at all?

As regards any specific changes and considerations with regard to the terms of reference for the HIQA review, I would need to go back and look at the paperwork involved. I do not believe I could give an answer here that would be satisfactory to the Senator. I cannot point to individual lines or clauses.

That is fair enough. The terms of reference were delayed. The Minister announced in late April that HIQA was going to carry out a review of emergency care and it took three months for the terms of reference to be agreed. The reason, which was legitimate, was that the Minister was waiting for the Clarke report. If the Minister does not have any memories of this instantaneously, it probably was not necessary. What really concerns me is the timeline. People in the mid-west cannot get their heads around why it will take HIQA nine months to come back with a comprehensive review. Whenever the date of the next general election is, the election will be over and the programme for government will be negotiated before this report is on the Minister's desk. Why has it taken so long? Can the Minister cut the timeline by six months and get this report on his desk by Christmas?

As I was saying earlier on, an interim report will be coming to me in February. The Senator is perfectly entitled to challenge me. I fully accept that. The only challenge I would make back is that his party held the office of Minister for Health from 2011 to 2020 and it is only now that a HIQA review is being carried out. While I accept the urgency of this matter, with respect, the Senator's party held the office I have the honour of holding from 2011 to 2020.

I do not dispute that. The Minister's party held the office when the emergency departments in Limerick and Nenagh were closed. If we want to do a history lesson, let us do a history lesson. I am talking about the HIQA report the Minister announced in April of this year, four years to the day, more or less, since the Minister took up his position. The Minister can take offence all he likes. It does not really bother me. However, people in Clare are asking, if it takes a year to decide whether an emergency department is necessary, how long is it going to take to build it. I will ask the Minister a straight question. He has been Minister for Health for four years. He has been working in the Department of Health for four years and I have no doubt that this issue is on his desk every day. I would never question his sincerity in this regard but, outside of any HIQA report, does he believe the mid-west should have a model 3 hospital and an additional emergency department? What is the Minister's own view?

That has been checked and the advice I have been given is that HIQA did not make such a recommendation. It did not recommend a second emergency department. I mention that for clarity. If the advice I am getting is incorrect, that is absolutely fine, but that is the advice I have.

My view is that there is a strong case for a second emergency department in the mid-west. That is why I have asked HIQA to do the review. HIQA previously referenced the potential for another model 3 hospital. That is essentially about more capacity, more beds, more theatres, more day cases and more outpatient treatments. As matters stand, the amount of additional capacity going into the mid-west is probably the equivalent of two model 3 hospitals. When we look at the increases at UHL, Nenagh, Croom, St. John's and Ennis, we see a total increase of close to 600 beds. We are already adding the equivalent of two large model 3 hospitals. I am posing the question of whether another emergency department on top of that is warranted. We have to let HIQA do its work. HIQA made it very clear to me that it needed time to do this. I am obviously very keen to get an answer as quickly as possible. This is difficult work. Some people will suggest investing in Nenagh Hospital, Ennis Hospital or St. John's Hospital as a model 3 and that an emergency department should be developed there. Others might say there should be a model 3 on the outskirts of Limerick city because that is the biggest population hub and for infrastructure reasons. Given the importance and sensitivity of the matter, HIQA was very keen to be given the time it felt necessary to give us the best answer it could. We did push HIQA and look for this to come back as quickly as possible. The timelines I have given the Senator are what HIQA has agreed to.

I have the shortest question. It relates to the medical assessment unit in Ennis running to midnight from next week onwards. I know there are plans to recruit nurses and consultants but I do not believe there are any plans to recruit clerical staff. That is what the unions have been told. To have all cogs moving fluidly, it is essential that happens. Will the Minister give us some positive indication in that regard or revert to us hereafter?

I thank the Minister and his staff very much for coming in. We have all found the information we have been given very interesting. As a committee, we took the unprecedented step of going down to visit UHL. Members expressed a number of reasons for this but we were all concerned by the really negative stories we were hearing about what was happening in Limerick. We were hearing stories for all the wrong reasons. We are conscious of all the positive work that is happening in Limerick hospital. We met the staff there. We met people working in discharge. There was great concern regarding staff, the lack of key personnel and the challenges in respect of the emergency department. As the Minister stated, those challenges are still there. As a member of the committee and as someone who is watching developments within Limerick, at times it was difficult to know who was in charge. We were hearing about different staff coming in. I am trying to be fair but, as outsiders, it seemed we were firefighting after certain tragedies and after hearing certain stories in the media.

We then had the awful story of Aoife Johnston. As someone who has read parts of the report, it seems there was chaos and a lack of key personnel to make those key decisions. Deputy Violet-Anne Wynne spoke last week about the nurses’ union, SIPTU, and the need for safeguards. I am aware the challenges that face University Hospital Limerick also face other hospitals. Yesterday, a son of a constituent of mine, an 83-year old woman, was told it would be better if his mother actually left the hospital because of how dangerous it was. These issues, therefore, are not solely confined to UHL, but it has been in the headlines for all the wrong reasons. Mistakes have been made in the past, such as downgrading certain elements of the hospital and trying to funnel everything through Limerick hospital and the challenges of that.

We did not really get the chance to discuss step-down care and beds in Nenagh. There is controversy over that.

This meeting has been really useful and we have got a lot of information. There are still a lot of questions, however. We may bring in the new chief executive officer at some stage if the committee has the time to do so. I appreciate the Minister, and many of his staff, tried to answer questions. I thank witnesses for the information they have given. I also offer my condolences, and those of the committee, to the family and friends of Aoife Johnston. It is only fitting we end the meeting on that point. The meeting is adjourned until Tuesday, 15 October at 4 p.m., when the committee will meet in private session.