The fact patient safety was not given the highest priority at corporate level in the Health Service Executive (HSE) was "disturbing, to put it mildly'', Taoiseach Enda Kenny told the Dáil.
He was responding to the Health Information and Quality Authority (Hiqa) report on problems at the Midland Regional Hospital in Portlaoise.
Mr Kenny said the fact that "people in the greatest hour of need were not treated with compassion, respect and dignity is an indictment of a health service in some locations".
He said there were accountability and disciplinary procedures available in respect of doctors and nurses, but not in respect of management.
The report, he added, was lengthy and complicated and Minister for Health Leo Varadkar would reflect very carefully on its contents.
Absolute priority
At the very least, a comprehensive response was required to ensure a culture of patient safety, as an absolute priority, was evident in the health services.
Mr Kenny said Mr Varadkar was engaging directly with the HSE directorate to ensure the report’s findings were addressed.
“It is only fair to say that the very least the families who have spoken out deserve is the tragic legacy is dealt with and, in so far as is humanly possible, it should never happen again,” he added.
Mr Kenny said he recognised the courage and dedication of the families involved in persisting and following through until the report was produced and published.
The Taoiseach was replying to Fianna Fáil leader Micheál Martin, who said the report made for shocking reading and presented "an appalling vista'' in terms of what happened in the hospital.
He said very senior people were aware of the systemic safety issues in Portlaoise.
Mr Martin said the report noted "the hospital is neither governed, resourced, nor equipped to safely deliver this level of clinical services''.
Clinical risks
Furthermore, he added, the HSE itself, in 2012 and 2013, had specifically identified clinical risks associated with surgery and emergency medicine, going as far as to say that surgical services at the hospital should cease.
Mr Kenny said the report had pointed out much had been done in the last period. All eight of the recommendations would be fulfilled, he added.
"New management is in place in Portlaoise and a memorandum of understanding has been signed with the Coombe to establish the country's first managed clinical maternity network in the Dublin midlands hospitals group, which is important,'' the Taoiseach added.
He said the quality and patient safety position in the hospital had been filled, and risk management had been strengthened.
On-site incident reporting had been introduced; 16 additional midwives were in place to reduce the ratio of midwives per baby born; and approval had been given for further midwifery posts to include shift leaders in delivery and posts in diabetics and ultrasonography.
Mr Kenny said the national mandatory reporting of serious patient safety events was in place. An improvised patient satisfaction survey last year indicated patients were much happier with the quality of the maternity services they received in Portlaoise, he added.
