I seek clarification on the last point on the Crumlin report. Is the Minister saying it was not commissioned because of potential poor outcomes, as happened in Temple Street, but it was commissioned because Temple Street had done a report? I ask the Minister to expand on and clarify that.

That is right. Representatives of CHI will appear before the committee on Thursday. The advice I have is that Crumlin hospital took it upon itself to do a similar review on the basis that concerns had been raised in Temple Street. The advice I have is that it was not based on concerns being raised and that it did not find an unexpected level of complication.

When exactly was that report commissioned? How many cases did it review in comparison with Temple Street?

I believe it was commissioned around September of last year and I believe 11 cases were involved.

The waiting list has not reduced despite the number of surgeries increasing. Does the Minister have any information as to why that is the case? Could it be that patients having unexpected further surgeries are being added to the waiting list? Therefore, they never come off or come off only for a short period of time because they have to go on.

This is one of the core questions we need to get to the bottom of. I am deeply frustrated that I do not yet have a satisfactory answer because I have posed this question to Children's Health Ireland on more than one occasion, as have my officials. We know there has been a very large investment and a really fantastic clinical workforce has turned that money into far more surgeries happening. However, the waiting list did not fall as it should have fallen. We have no evidence there is a higher incidence of scoliosis or spina bifida in the country. Therefore, why are additional reviews coming in? Is it because now that there is additional capacity, children with lower levels of acuity are being referred in who might not have been referred in previously? The Deputy's question is exactly the same question I asked. Is it actually because the children involved are receiving more care and the number of children involved has not increased at the same level as the number of surgeries? I assure the Deputy this is being pursued rigorously with CHI. It is one of the things I will be raising with the reviewer on Monday. At this stage I want an independent external expert answer to the question the Deputy has raised and the question I have been posing for some time.

It is incredible because the questions are simple. There are large waiting lists for those with spina bifida and scoliosis, but we are not dealing with tens of thousands of children. It is a quantifiable number. It does not provide any confidence when the Minister cannot get answers. They do not need to be detailed answers, but just general answers to those questions. Surely these clinicians will know if the children on these waiting lists are coming in for repeated surgeries or are brand new. Surely someone senior in CHI should be able to tell the Minister that over the course of a short conversation. It is quite concerning that he has been unable to get that information.

The Minister said that will be subject to a review. Is that part of Mr. Nayagam's review or will it be part of a different investigation or review?

It will be part of Mr. Nayagam's review. The third objective is "To assess the governance of the Paediatric Orthopaedic Surgery Service and to make findings, [that is right across the board] and to make any necessary recommendations in regard to improvement in governance including quality, safety, outcomes and performance metrics." Dr. Colm Henry and I have spoken directly on this. I have instructed very clearly that this issue be looked at and that waiting list management be looked at. The State has invested the money. We have really dedicated healthcare professionals who are working very hard and doing extra sessions and using the extra resources. They are doing much more surgery.

I share the Deputy's frustration. I have asked the question repeatedly. I have asked it of officials who are engaging with CHI and I now want the external reviewer - as well as CHI - to come back to me with a very detailed answer to this question. To date I have had answers, including reference to increased referral from other parts of the country - people seeing that the service rate is expanding and referral rates increasing. I agree entirely with the thrust of the Deputy's questions.

CHI has been at pains to stress that spinal surgeries are continuing. Is the specific procedure, kyphectomy, continuing at the moment or is it paused for lack of the relevant expertise, for want of a better phrase?

I will double check the exact details, but my understanding is that it was paused last November. It is still paused and the last kyphectomy procedure happened in the middle of last year, perhaps in July 2022. It was officially paused in around November, but we can get the Deputy the exact dates.

Does the Minister have information on the impact for that particular procedure? I am not sure if it is captured in a particular waiting list. Has the waiting list for that particular procedure increased in that time?

I will get the Deputy exact details. I do not have it in terms of individual surgeries that are being recommended for particular patients. However, the reality is that we have two surgeons who do complex spina bifida care and it is done in Temple Street. One of those surgeons is currently not doing those surgeries. Will that have an effect and is it already having an effect on the time these children are waiting? Yes, unfortunately it is. That is being taken deadly seriously. As I alluded to earlier, all potential solutions are being looked at.

On the procurement procedures in Temple Street as it related to the non-regulated springs, has the Minister asked for any immediate measures to be taken there to ensure that no loose procurement or loose procedures are taking place for any other devices for any other types of surgeries in this hospital or in any other hospital?

Yes, I have. The clinical director is very clear that in CHI and in Temple Street additional communications and additional protocols were put in place. As they would say very clearly, there are already numerous protocols in place in every operating theatre in the country to ensure things like this do not happen.

We need to appreciate that the backdrop to this is that the State has failed the children who are most medically challenged. Despite repeated promises, the scoliosis plan, three Ombudsman's reports, three reviews which have been completed, umpteen Dáil debates and umpteen media reports, we still do not have adequate services for those vulnerable children. It is no wonder that trust has broken down and this week's events have not helped in any way. There is an impasse there at the moment. We need solutions and we need to be able to move on.

The advocacy groups have asked for two things. The first has been conceded, which is that the Taoiseach will meet them this week, and I welcome that. The second is that the terms of reference for the latest review have input from them. I think that is perfectly reasonable. I know what the Minister is saying, that it is up to the doctor concerned to extend the terms of reference if he believes that is necessary. I want the Minister to go further than that and the parents want him to go further than that. They want him to mandate the doctor to take on board their concerns about the terms of reference. Will he do that?

I certainly can but there is no need because that exact process is already built into the review.

They do not believe that.

Let me state clearly that it is absolutely the intention and has always been the intention that the families directly meet with the lead reviewer. The terms have been crafted such that he adjusts them depending on what they say. As I said to Deputy Cullinane earlier, with the benefit of hindsight, that process should have happened twice. It should have happened before the draft terms were published rather than just being shown the draft terms. I fully accept that should have happened. That was a mistake. It was intended and will happen exactly as the Deputy said.

Deputy Shortall said something very important. Has the State failed these children? Yes. Yes, the State has failed these children and the State has been failing these children for years. Of the €19 million we put in last year, and I ask the Deputy to bear with me for one second if she does not mind, 168 additional healthcare workers are funded and 151 of those are in place. We will not rest until those waiting lists are brought down.

That is welcome. To clarify, is the Minister saying the advocacy groups will have an input to the draft terms of reference before they are finalised? I think that is really important.

Yes.

Okay. That is very welcome. I thank the Minister. On the matter of the Crumlin report being published, I welcome that. I tabled a parliamentary question on it and look forward to seeing the answer on Thursday. Can the Minister clarify if that report will cover the use of what are known as the magic rods in some surgeries?

The advice I have right now is that they do not believe so but we will double-check. That review was done for a small number of children in Crumlin.

Can we see the terms of reference for that review?

I am sure we can.

Okay. Many different reviews are being referred to. Can the Minister tell me who in Temple Street was aware of the proposed use of the non-medical devices? Was their use discussed with management? Has he any information about that? As far as he knows, did they go through the procurement process and the standard protocols?

I thank the Deputy. This is exactly what the additional review is looking at right now. Of course I have spoken to CHI and the HSE. My officials are engaged. I have a view on some of those questions. However, I am very much of the view that we have to establish the full facts. We have to establish who, at a management and a clinical level, knew what. This relates to several questions. First of all is the use of the springs in the operation. We know it was an operation that was being trialled in Utrecht, for example. Probably more pressingly, the fact is that they were not medical grade and were not authorised for this use. A review is going on now to establish exactly who knew what on all of those areas.

Has the Minister a timeline for that review?

The framework timeline is four months. I ask the Deputy to bear with me. When I heard that, I made it clear to CHI that I and the Oireachtas would not wait for four months to get answers to these questions. I have asked for it to be accelerated for that reason.

Who is carrying out that review?

CHI is carrying out that review. I beg the Deputy's pardon. Sorry. It is an external review.

Who is doing it? Do we know?

The advice I have is that people from Cork University Hospital and other procurement experts are doing it. I will provide details on exactly who is doing that.

What is the oversight? We need to get away from people policing and investigating themselves. There has been too much of that. What is the oversight?

It is an external review that, in the first instance, I believe will be reporting to CHI and the chief clinical officer of the HSE.

That is not acceptable. Allegations are being made that this was all known about within Temple Street at a senior level. I do not know whether there is a basis to those allegations or not, but they should not be left hanging in the air. We also know that there is an end-to-end procurement procedure, from the purchase of them, and I understand the hospital paid for them, up to the sterilisation of them before implantation. We need to know how they were implanted in three patients. What were the discussions, if any, around those? It is critically important that is an independent process in which people have confidence.

We need very clear answers to every question the Deputy just raised and many more, end to end. What has happened here is very serious. There is an external group which is reporting to the CHI board. However, I take the Deputy's point and agree with her point about trust. There must be trust in the answers. I absolutely take that on board. In addition to that, if we need to do an additional short, independent one, we can. Dr. Nayagam's review is also looking at the issue of the springs and all of these questions.

We have been told it could be a year, if not longer, until Dr. Nayagam reports. The general principle is that justice delayed is justice denied. Too often, we see a major problem being put into a review and who knows when we will ever get the results of that review, and it will be redacted. All of these things generally happen. That is not good enough in these circumstances. Will the Minister ensure that either the HSE or his Department takes oversight of this report? This goes to the heart of the question of trust.

Two separate groups are looking at this. We have discussed one. The second is Dr. Nayagam. We need to be clear that nobody will be waiting a year for a view from Dr. Nayagam and this review. There will be interim reviews and it is being set up such that the pressing clinical issues are reported on this year. The reason people are saying the review in its totality may take a while is that I and others have insisted it is a broad review. That takes time. The clinical safety issues we are discussing right now will be reported on to me and I will report to this House much quicker than that.