Dáil Éireann debate -
Thursday, 26 Apr 2018

Vol. 968 No. 2

Leaders' Questions

Deputy Dara Calleary

Everybody who yesterday evening listened to and watched Ms Vicky Phelan telling the story of how her cervical smear test was processed and then misdiagnosed, and then nobody actually had the courage to tell her about that for up to three years, would have been struck by the amazing courage and bravery of Vicky and her family. Vicky is a young woman, only 43, a wife and a mother of two children, aged 12 and 7. She was given the all-clear health wise following a cervical screening in 2011. However, in an internal audit carried out by CervicalCheck in 2014, Vicky's 2011 smear test was found to have had abnormalities. No-one informed Vicky, her family or her doctor about that audit or that result for another three years. I know the Tánaiste would agree that it is beyond words that Vicky had to face the prospect of terminal cancer, or the fact that information was knowingly withheld from her and her doctors which makes it completely inexplicable and frankly absolutely unacceptable.

However, the 2014 audit has also found incorrect results in up to 14 other women's tests. Yet it was only in 2016 that medical consultants were advised to deal with these women and tell them their results. Court documents suggest that CervicalCheck issued a circular in 2016 saying that the service would like the women's notes to be reviewed, and for the result to be "recorded". The circular also said "as a general rule of thumb the outcome should be communicated to the woman with a focus on the context of confronting the overall clinical scenario."

CervicalCheck then explained that the women may not have been aware of the actual audit. The approach has been cruel and bizarre in the extreme. It was also reported that doctors were asked to use their own judgment on whether to inform women about these misdiagnoses. This is absolutely unbelievable, particularly when Vicky and the 14 others were given the all-clear result years before.

How is this acceptable, medically, ethically or legally? Was the HSE aware in 2014 that the audit had taken place and was it made aware of the results in 2014? This programme is hugely important to our country, but given that it is paid for by the State, the company that undertakes and rolls out this programme must have obligations to the HSE concerning the way it informs people. Is a protocol in place between the HSE and CervicalCheck about audits and the sharing of information? If not, why not? How many audits have taken place since 2014 and how many other women are in the position faced by Vicky today? Finally, can the Tánaiste outline what will change as a result of what we know now, as a consequence of the bravery and the courage of Vicky Phelan?

The Tánaiste

I thank the Deputy for raising this issue. I think anybody who has listened to this story or read about it will come to the conclusion that this was a shameful series of events, particularly where information flow is concerned. The tragedy and challenges that Ms Vicky Phelan and her family are facing now have been made all the more difficult because of the failings in passing information on. For that, as Tánaiste I want to apologise to her and to her family.

It might be helpful for me to put on the record what is going to change as a result and how that has come about. In 2014, at the time when Vicky Phelan was diagnosed, CervicalCheck initiated clinical reviews for all notified cases of cervical cancer arising from screening. At that time, the information was used to inform improvements in the system and was not communicated to clinicians or to patients. This changed in late 2016, and subsequently current and historical outcomes of the audit process were made available to clinicians for communication to their patients on request. Ms Phelan rightly contends that she should have been made aware of the outcome of the audit process which related to her in 2014, and we agree with that. It has now been decided that patients will be advised as part of the process in the future. That will not be optional. It will be automatic. A process is also under way to identify any other women affected in the same way as Ms Phelan to ensure that they are informed as is necessary.

Each year, approximately 250,000 women have a cervical cancer screening, or smear test as most of us would know it, through CervicalCheck. CervicalCheck has found over 50,000 pre-cancerous changes in women, leading to appropriate early treatment, which of course is what this is all about. It is important to say that while this case is tragic and should not have happened in the way that it did, we cannot allow it to undermine confidence and faith in CervicalCheck as a whole. This is a screening programme. There is no such thing as a perfect screening programme. Mistakes can be made and mistakes were made in this case. However, it is true to say that cervical cancer screening aims to reduce the instance of mortality in cervical cancer. Instances of cervical cancer in Ireland have fallen by about 7% annually and continue to fall and CervicalCheck is playing a big part in that. However, that is no consolation to the Phelan family today.

What I want to say is that it is regrettable that Ms Phelan needed to take court action to establish the truth. It is certainly regrettable that decisions were not made before now to require patients to have automatic access to information that relates to them. That applies particularly in the cases of women who are diagnosed with cervical cancer, where audits automatically take place if they have previously been through a screening programme to establish whether any mistakes were made. Hopefully that answers some of the Deputy's questions.

Deputy Dara Calleary

We all agree on the importance of the CervicalCheck programme and the necessity to have full confidence in it. We need to restore this confidence. Anyone who listened to "Morning Ireland" this morning will not have had confidence in the information that was processed and presented. Will the Tánaiste confirm that the other 14 women identified in 2014 have been informed of their specific circumstances and that communication is open with them? Will he outline what will be done to ensure CervicalCheck realises the seriousness of this matter and what steps the organisation will take to rebuild public trust in this vital screening programme? Will the Minister for Health make himself available in the House next week to answer questions on this matter? Deputies and Senators may learn of concerns over the weekend that will need to be addressed next week as part of the process of beginning to rebuild trust in this vital screening programme? The Oireachtas must also outline its responsibility to Vicky Phelan and her family.

The Tánaiste

I heard the interview this morning, which raised some questions and did not provide full clarity in terms of the Health Service Executive's response. The clinical director of CervicalCheck has spoken on radio in the past hour and provided much more clarity on the issues. I thank both individuals for their efforts to bring clarity. I am sure the Minister will be happy to deal with questions as they arise. He has already met the directors of the HSE and the National Cancer Control Programme to discuss these issues and try to ensure we maintain confidence in a system that is vital to Irish women in terms of reducing the incidence of cervical cancer.

In terms of lessons learned, I assure Deputy Calleary that this matter is being taken extremely seriously by everybody concerned. For this reason, quick decisions have been taken today, not only to review but also to change the approach in terms of automatic entitlement to access information relating to patients, as opposed to relying on the judgment of a clinician or doctor to pass on that information.

Deputy Dara Calleary

I asked a question on the other 14 women concerned.

The Tánaiste

Work is under way to establish whether there are other women in the same category, that is, women who have not received the information they should have received. We will have more details when the work has concluded. It is not expected that there are many more women in this category but that needs to be confirmed. I hope the work will be completed quickly.

Deputy Donnchadh Ó Laoghaire

I, too, raise the case of Vicky Phelan. Anyone who watched or listened to her making a statement outside the Four Courts yesterday could not help but be moved by her heartbreaking words. Mr. Justice Cross described Ms Phelan as one of the most impressive witnesses he had ever encountered. She is a remarkably brave and courageous woman and I extend solidarity and support to her and her family at this extremely difficult time.

The details of Ms Phelan's case are shocking. To provide a timeline, on 24 May 2011, Ms Phelan had a smear test. She was given the all clear on 17 June 2011. On 9 June 2014, her next smear was found to be symptomatic and this triggered her inclusion in the review taking place at the time, which found, on 31 October 2015, that a serious error had been made. On 21 July 2016, Ms Phelan's doctor was informed of this but it was not until 27 September 2017 that Ms Phelan was informed. It is my understanding that the period between 21 July 2016 and 27 September 2017 is filled with correspondence between her doctor, Dr. Kevin Hickey, and Professor Gráinne Flannelly. I understand there was a dispute as to who had the responsibility to inform Ms Phelan. It seems that in all these cases the last person to know is the woman affected. According to Ms Phelan's solicitor, Mr. Cian O'Carroll, if her cervical cancer had been detected in 2011, Ms Phelan could have undergone treatment and stood a 90% chance of being cured. She now has terminal cancer.

Other women listening to Ms Phelan's story will be worried, confused and frightened. Documents from Ms Phelan's case indicate that up to 14 other women diagnosed with cervical cancer had previously been told their smear tests were normal. Anyone seeking reassurance will not have found it this morning if they listened to an interview with Dr. Jerome Coffey. In response to straightforward questions, Dr. Coffey obfuscated and avoided answering. He was not able to state how many women had been affected by misdiagnosis or whether all of them had been informed. He could not even indicate whether doctors were obliged to inform patients who had been misdiagnosed. While I did not hear the interview with Professor Flannelly, I was informed of it and significant questions remain outstanding. How many patients were misdiagnosed and have they been informed of their misdiagnosis?

I understand there is a contractual obligation to inform women within four weeks if a problem is identified with a smear test. If a problem is found in a subsequent review, why does a similar contractual obligation not apply? Given the contractual obligation to inform women of problems identified in a smear test, why are women not told as soon as possible of problems identified with a smear test in a subsequent review?

The Tánaiste

In answer to the Deputy's final question, that is what we are changing. Many of us listened to Vicky Phelan who is an incredibly courageous woman. In the midst of all the challenges she is facing, she focused on the hope that something good may come from this. I hope that is the case and we have an obligation to ensure it is the case. The key issue is the information flow. Once the State has a piece of information that is relevant to a woman in these circumstances, she should be entitled to have this information immediately. It should not move between offices, physicians or anyone else without the patient having automatic access to it. The decision taken this morning was to change the approach and not before time.

It is important that we use accurate language in this discussion. This is not about misdiagnosis. A smear test is not a diagnosis but a screening mechanism that can spot early signs of change which need to be followed up in terms of potential cancer treatment. This is different from a full diagnosis. In this case, we had what was effectively a false negative from the screening programme. Such false negatives occur because there is no perfect screening programme in place anywhere in the world. The view of those involved in CervicalCheck is that the systems in place here are as good as those in place anywhere in the world and better than most. In that regard, CervicalCheck is open to peer review, independent assessment and so on.

Unfortunately in this case, there was a false negative. When Vicky Phelan was subsequently diagnosed with cervical cancer, the audit and checking system, which operates in all such cases to ascertain whether somebody who has a diagnosis of cancer previously had a smear test, found that the result of the smear test was incorrect. Ms Phelan's solicitor has raised the question as to whether the story would have been different in terms of treatment options and so on if this had been known earlier.

The key issue, as Ms Phelan correctly noted, is access to information. We will change this immediately to ensure that anybody who is in a similar position in the future will not have to access information through the courts, which is how Ms Phelan had to do it.

Deputy Donnchadh Ó Laoghaire

Information is, clearly, part of this. I have already said that it is disgraceful that she was the last to know, as was the delay before she was informed. It appears that there was almost a battle between the doctors and CervicalCheck as to who had the obligation to tell her. That is wrong. It is disgraceful. However, there is more to this than knowledge. Professor John Shepherd is one of the medical experts called in this case. He said he was struck by the obviousness of the abnormalities found on the slide which was reviewed. They should have been spotted speedily. These US laboratories have been used for ten years or so and concerns were first expressed about them by organisations such as the Well Woman Centre in or around 2007. Of course, there will be mistakes. It is not possible to have a programme in which there are no mistakes. Nevertheless, it is worth asking whether we are going to engage in a review of the rate of misses from these laboratories. Such a review is vital to restore public confidence. This is a very important programme and we all want it to be funded properly in order that as many people as possible might be screened. However, we need to know that the quality of checking in those laboratories is up to scratch and that there are not more things being missed in them than are missed anywhere else.

The Tánaiste

I accept absolutely that we have to ask all of the hard questions after a case like this. However, I want also to reassure people, particularly those outside the House, that CervicalCheck rates very well in comparison with similar screening systems in other parts of the world. There is no perfect system and human errors will occur in screening programmes, particularly with 250,000 people a year having smear tests. That seems to have been what happened here, but I do not know for sure. I know, however, that this screening system is open to independent assessment, if that is what people are seeking, in order to show that it rates well by international standards. All of us have the responsibility, however, to reassure women that this is a good screening programme which is saving lives, albeit we need to assess it constantly to ensure that improvements which can be made are made. As to information flow within the health system, that is a correction we are making this morning. Nevertheless, it is essential to reinforce the importance of smear tests and CervicalCheck in general in light of the number of lives it saves and the reduction by 7% per annum in the number of women diagnosed with cervical cancer on foot of the programme. Having said that, questions must be answered. If necessary, an independent assessment should be part of the follow-up process.

Deputy Donnchadh Ó Laoghaire

What about the US contracts?

The Tánaiste

Well-----

An Leas-Cheann Comhairle

I call Deputy Michael Healy-Rae. I provided an extra minute for Deputy Ó Laoghaire's question, which, I know, relates to an important issue.

Deputy Michael Healy-Rae

In recent days, an agreement was reached between the Irish Postmasters' Union and An Post on the future of our post office network. As I could be perceived to have a conflict of interest in this matter, I note for the record that I am the proprietor of a small post office in a rural area. In addition, I wish to place on record my appreciation and gratitude to the Minister for Communications, Climate Action and Environment, Deputy Denis Naughten, who has been diligent in his work on our post offices, and others. However, I wish to highlight what is actually happening. In the county I represent, we do not have many post offices. Of those we do, 26 have received letters informing them of an offer to close their doors. This has happened on foot of inaction on the part of this and previous Governments, which have failed to support our post office network despite a commitment to do so in their programmes for Government. The value of An Post's contract in respect of social welfare payments has decreased from €60 million to €51 million and continues to decline.

Some of the post offices which have been offered compensation packages to close may accept them because the postmasters feel they have no choice. The communities served by these post offices include among their members community activists and leaders. Post offices in east Kerry, mid-Kerry, north Kerry, south Kerry and west Kerry, along with post offices throughout the rest of Ireland, have been notified of the offer to close but the communities involved do not yet know about it. Post offices which have not been told that they can close have been offered a contract, signing which would be akin to signing one's own death warrant. I have studied the contract. One would want to be a barrister to read it given the extent of what it involves. Ultimately, it means that people will have to work for far less remuneration while their prospects for the future diminish over the next three years. I have always used the following figure since I entered the House. Unless serious action is taken by Government, 700 post offices could close.

I acknowledge the work of Deputy Dooley, who met even yesterday with representatives from An Post. His timing is very good. He has been diligent about his work as Opposition spokesman and very vocal on the issue. However, there has been a very serious result. Neither the package to close nor the contract is any good. The Government will have to take on board the problems we have if we are to have any hope of saving the majority of the network.

The Tánaiste

I compliment the Minister, Deputy Naughten, on his determination, which I have witnessed over and over again in Cabinet, to ensure that the post office network remains part of the physical infrastructure of urban and rural Ireland. He has repeatedly confirmed the Government's commitment to ensuring that the infrastructure remains intact. We have seen a commitment to explore the potential to channel more Government business through the network, including motor tax, and the Minister's Department is engaged with other Departments in this regard. The Minister for Rural and Community Development, Deputy Ring, will announce shortly a pilot "digital assist" initiative which will use the local post office network as a digital gateway for Government business. The Government has committed to State funding of €30 million for a project with An Post. The funds have been provided by way of a long-term loan advanced from the Exchequer to be used to support the renewal of the post office network and the continued fulfilment of a five-day per week mails delivery service. In turn, this will secure the future of mail and post offices services for local communities nationally in both urban and rural areas. In addition, An Post proposes to invest a further €50 million in the network in the next few years.

There is a partnership between the State and An Post to ensure that the company has a viable future. An Post's commitment is that there will be no compulsory closures while there will be some consolidation to ensure post offices are well located. The transfer of business to neighbouring offices will ensure the continued viability of smaller offices in meeting the needs of communities. An Post will open up to 20 new offices in communities of 500 people or more which currently lack post offices.

A post office will be guaranteed for every community of over 500 people and within 15 km of 95% of the population or, in an urban area, within 3 km. I hope what we have now is an agreement between the postmasters and management in An Post on a future development plan for the company. This is very much supported by the Government, both financially and from a policy perspective. It will ensure post offices will remain a feature across rural Ireland, as well as in urban environments.

Deputy Michael Healy-Rae

I appreciate the work done by people like Debbie Byrne, who is in charge of promoting more retail through our post offices, and David McRedmond. The Tánaiste claimed there are no compulsory closures. He is 100% correct. However, over the past two days, 390 letters went to post offices around the country, out of which 26 went to post offices in County Kerry. If 26 small factories were being offered a closure package in County Kerry, there would be outrage. Even if half or ten of those post offices took up the offer, it would be an awful loss to those communities. It will tear the heart and the soul out of our communities in which we want to keep people living. The same has happened in Donegal, Limerick, Clare and all over the country.

Quite simply, the Government is not acting quickly enough to save the post office network. We cannot blame a postmaster for availing of these packages if their footfall is going down because not enough customers are going into their post office. If they see no way out of it, they will accept it and they will close. Once a post office is gone, it is gone forever. It is in the programme for Government. Will the Tánaiste do more and do it quickly to save as many post offices as we can and not allow them to close?

The Tánaiste

We are working with An Post to ensure we have as many post offices as possible. There are no compulsory closures. If certain postmasters choose not to stay open-----

Deputy Mattie McGrath

They will be forced out.

The Tánaiste

-----then there will be the option to transfer the business to another business locally or to another post office if it is within a certain range. The whole point is to ensure An Post has a future. Up until six months ago, this was a company with a bleak financial outlook. We now have a situation where An Post is back in profit and we need to ensure it remains so permanently. We must use An Post's entire infrastructure to the fullest possible extent, recognising it has a role in rural community infrastructure, which the Deputy knows only too well about because of his own involvement. The Government is very aware of this role. The Deputy and I have spoken in government formation talks about the importance of the post office network. That is understood in the Government, particularly among rural Deputies. It is led by the Minister for Communications, Climate Action and Environment, Deputy Naughten, who has worked with An Post to ensure a viable plan is in place and one with which the postmasters can agree.

An Leas-Cheann Comhairle

I call Deputy Healy-Rae. I apologise, I meant Deputy Seamus Healy.

Deputy Michael Healy-Rae

I thought the Leas-Cheann Comhairle was giving me another crack at it. I do not mind continuing.

An Leas-Cheann Comhairle

I know the Deputy does not mind. He does not always look for permission to do so either.

Deputy Seamus Healy

Children and young people are being failed by our mental health system. For the past three months since February, young people experiencing mental health difficulties have been admitted to the paediatric ward in South Tipperary General Hospital. Today, there are three young people on the ward. There have been as many as five and their lengths of stay have been as long as eight weeks. The reason for this, as we all know, is that there are simply not enough inpatient beds for young people with mental health difficulties.

Admissions to the paediatric ward in South Tipperary General Hospital are totally inappropriate. Nursing staff do their best. They are kind, compassionate and caring but they are not trained to provide mental health care. Parents, usually mothers, must stay on the ward overnight to give support to their children. Of course, there are knock-on effects in delayed admissions for other patients. Every day, young people with mental health difficulties do not receive the age-appropriate timely services and supports they need. This causes psychological and social damage to these young people. It has a detrimental effect, not just on themselves, but also on their parents, their siblings, their schools and their communities. Of course, it reinforces the whole stigma regarding those with mental health difficulties. Children and their parents face immense challenges to get an adequate, or indeed any, service. Due to this, many children carry those difficulties into their adult lives.

We all know what needs to be done. We have had report after report. The problem is we have had no action on those reports or their recommendations. I remind the Tánaiste that to tackle this significant issue, we need additional inpatient beds for children and young people with mental health difficulties and 24-7 crisis intervention teams providing rapid assessment for those children and young people. We need a comprehensive primary care counselling service and a fully staffed existing child and adolescent mental health teams. We also need to resource and support, including financially, community and voluntary organisations working in these areas. We need a designated leader - a tsar-type arrangement - whose sole duty and responsibility will be to drive the implementation of these measures to ensure our young people get the services they deserve and need urgently. It should be like how cancer care services developed recently.

When will we see these measures being implemented by the Government?

The Tánaiste

I will ask the Minister of State, Deputy Jim Daly, to revert to the Deputy with more details on South Tipperary General Hospital after Leaders’ Questions. He is aware of some of the cases to which the Deputy referred and he has spoken to some of the parents involved.

Staffing and necessary skills shortages need to be addressed in the context of extra beds. Up to €55 million of additional funding has been committed for next year to develop new services, which will involve ten new beds in the Central Mental Hospital and 20 new child and adolescent mental health services, CAMHS, beds coming to the new children's hospital. There is a recognition that there is a deficit. We are providing significant resources to address that.

On the broader mental health service issues, funding this year is almost €1 billion at €910 million. That is an increase of €200 million since 2012. In excess of 2,000 new posts have been approved since 2012, of which over 1,300, 66%, have been recruited with recruitment ongoing for the remainder. The appointment of 114 assistant psychologists and 20 staff grade psychologists for primary care child psychology services is ongoing. A series of actions are happening which are linked to reports which have been done. This represents incremental improvement all the time.

However, I am aware there are certain pressure points in different parts of the country. This is a particularly sensitive area in child and adolescent mental health services. We have seen significant increases in funding and funding commitments with the staff and beds that need to go with that. The challenge is ongoing. I will ask the Minister of State, Deputy Jim Daly, to come back to the Deputy with a more detailed answer on services in Tipperary.

Deputy Seamus Healy

While I thank the Tánaiste for the reply, we cannot continue to kick this can down the road. These issues must be dealt with urgently. The Tánaiste referred to recruitment. There are currently 500 psychiatric nurse vacancies in this country. The position would be much worse were it not for the tremendous work done by community and voluntary organisations across the country. There are many such organisations in my own area, including the River Suir Suicide Patrol, Taxi Watch and C-SAW, the community suicide awareness workers. These all operate on a voluntary, unpaid basis and do tremendous work. There is huge frustration among these organisations, which feel alone in dealing with issues that should be properly dealt with by the public mental health service. These organisations need to be acknowledged, supported and resourced, along with financial support.

We are failing to provide for our young people. We need to do so urgently; it must become a Government priority. We cannot, should not, and hopefully, will not kick the can further down the road in this. They need to be implemented urgently-----

An Leas-Cheann Comhairle

Go raibh maith agat.

Deputy Seamus Healy

-----not in the next budget but now, because this is something that is affecting young people on a minute by minute basis.

The Tánaiste

I reaffirm to the Deputy that no one is kicking the can down the road on anything here. It is a programme of action that is already under way. The construction of a national forensic mental health complex at Portrane is progressing well and should be completed by 2020. There are other improvements such as in counselling services, including new Jigsaw sites in Cork, Dublin and Limerick, to bring a total of 13 sites nationally, and there is continued development of the community mental health teams and improved 24-7 response and liaison services are improving the contact within communities. An eating disorder care programme was launched in January 2018, which is patient-centred in care and recovery. In line with the provisions of A Vision for Change, the HSE has prioritised mental health needs for those under 18 years. We are focusing on reducing CAMHS waiting lists and improving mental health teams. There are currently 69 CAMHS teams nationally. The Minister of State, Deputy Jim Daly, is working with the HSE and officials to establish a national telephone and text line for mental health services, and the list goes on. There are a lot of things happening in this area but there is a lot more to be done, and we recognise that.