The Minister said he was informed on 4 August about the use of these unlicensed implants. When was he informed about the fact that there were allegations of use of unlicensed implants at Temple Street?

When was I informed of what?

Of allegations that this was happening. Is 4 August literally the first time the Minister heard that there were allegations and when it was confirmed? Did he hear about an allegation at any point previously?

What I had was Deputy Murphy's parliamentary questions. He can correct me if I am wrong but the information I have is that the first time his parliamentary questions were specific to the point that these could be identified was 27 July. If I am wrong, please feel free to correct that.

They were submitted on 13 July and the Minister answered them on 25 July.

Okay. They were submitted in July. I have looked carefully at this. As I see this, the Deputy asked a series of escalating questions. To begin with, they were quite vague. They are all on the record. They were about whether CHI uses non-medical-grade equipment. I believe it replied in good faith that, to the very best of its knowledge, of course it did not use non-medical-grade equipment. It was only in the second week of July, I believe, and I am more than happy to be wrong on this, as I read it, that the Deputy's question became specific enough for CHI to look exactly at what he was pointing to. When it found that, it responded on 27 July and I was informed the following week. I do not know what the Deputy was given but if he had that specific information earlier, I could have acted on it and CHI could have acted on it. If the Deputy has information to the contrary, that is absolutely fine. It is important to say that I believe it was only in July, when his question became specific enough, that CHI was able to identify what he was pointing to.

Let us even take that. The Minister says 4 August, but on 25 July, the Minister responds to detailed questions. He does not respond with detail and he kicks it off to CHI, which is the process, and I still do not have an answer to those questions from CHI. Therefore, the Minister was aware of the allegations at what time - was it 25 July?

I will have to check. Let me answer the question directly again to be absolutely clear. I was informed of this issue, and my date might be slightly wrong, I believe on 4 August.

I asked the Taoiseach about it on 5 July in the Dáil and I spoke about the allegations that unlicensed implants had been used in children, and the Taoiseach said he was going to talk to the Minister about it. Did the Taoiseach talk to the Minister about it?

I will have to check and I will have to check if his officials passed on those comments, as that would normally be what is done. Again, the details to CHI that allowed them to find what it was the Deputy was pointing to happened in the second week of July. It was discovered in the following weeks, when they looked into it, and I received a report on it on 4 August. I then asked a series of detailed follow-up questions on the report that I got.

The Minister said he always wanted to see the publication of the external review. I asked him about that in mid-July. I asked about publication and, at that stage, the Minister did not say that, although he said it would be communicated to people appropriately. Why did he not say at that stage that he was going to publish the report?

I will have to take a look at the parliamentary question answer. The chief clinical officer got a copy of the report in July, a copy of the report will have been sent to me in August, there was a disclosure process gone through with the families and then there was a proposed publication date after full disclosure had been gone through with the families. The report in The Ditch was ahead of full disclosure having happened with the families, which led to the report’s publication being accelerated. Specific to the publication of the report, it was not the view of CHI that the internal or the external reports were going to be published. Their view was that they were going to publish this condensed version. That was never acceptable to me and it was never acceptable to the HSE, and both the chief executive and I intervened directly to state that both reports needed to be published in full.

Then the question is why it took so long. A specific question was put to the Minister and I got an answer from CHI in May, so the question must have been put in April. The question “asked the Minister for Health if he is aware of any external or internal pressure being placed on clinical staff at Temple Street to restart spina bifida-related surgeries in advance of the conclusion of the external review”. It concerned restarting kyphectomies despite the fact that they knew about these complications and they knew that one person had tragically died. CHI says it is not aware of any internal or external pressure. Did the Minister just accept that like he just accepted all of CHI's answers, which I had to accept as I did not know anything better? CHI is telling me that everything is normal to the best of its knowledge and that it is not using unlicensed implants. Does the Minister now accept there was pressure put by management on surgeons to restart?

On the parliamentary questions, I know this is never satisfactory, and I got the same answer when I was on that side of the House and I never found it particularly satisfactory. However, I receive about 15,000 to 20,000 parliamentary questions a year, so colleagues will appreciate that none of us can write all of our own responses to every parliamentary question. However, I am responsible for them and it is my name at the bottom of the page.

On the question the Deputy asks, I am not aware, nor am I aware of any suggestion that has ever been made to me, about pressure - presumably, we are talking about inappropriate pressure - being put on clinicians to do procedures which they did not believe were clinically appropriate to do. If that is the thrust, no, I am not aware of any such pressure.

I am telling the Minister that was the case in March. I want to go back to the timeline. I think the Minister accepted that the reason things were published and processed was the article in The Ditch. I want to go all the way back to last year. Does the Minister know that the first freedom of information requests, FOIs, from the journalist, Pádraig Ó Meiscill, were submitted in October, then the surgeries or kyphectomies were suspended in November and then the internal review started? Does the Minister accept that the reason this whole thing kickstarted was not some internal process but external FOIs from a journalist?

I am very open to an external review telling me whatever it finds. What I can tell the Deputy right now is that this is the first time I have heard this. This is the first time I have heard about an FOI. The clear advice I have been given is that there were serious patient safety incidents, the protocols were followed, the patients and the families were engaged with and I was informed. To Deputy Cullinane’s earlier point, arguably, I was informed in too tardy a manner on the July one. In the September-October-November period, two things happened. There were patient safety incidents which were being looked at and the spina bifida multidisciplinary team in Temple Street raised concerns. On the back of that, two reports were commissioned, an internal CHI report and an external Boston Children's Hospital Group report. I am very open to any external reviewer telling me that FOIs played a role. The Deputy’s question is the first time I have been aware there were any such FOIs.

Does the Minister accept there needs to be a spinal surgeon on the external review?

The Minister can answer that afterwards because we have to move on. I thank the Deputy for his co-operation.

I want to check the timeline between the Minister and the Taoiseach on the communication. To be honest, it is extremely nebulous. The Minister stated that he learned of it for sure at the start of August and that he told somebody in the Taoiseach's office. Who did he tell in the Taoiseach's office?

That is not what I said at all. What I said is that there will have been communication between officials and advisers between the Department of Health and the Department of the Taoiseach. I believe there was communication in July and August and, obviously, in September, and we can provide a full timeline as to those exact communications.

Did the Minister not think something like this was worthy of speaking to the Taoiseach directly about?

Yes, I do.

But you did not.

It is important to say, though, that we receive 20 to 30 of these patient safety incidents on an ongoing basis. Yes, it is worthy of communication. There was communication, I believe, in July and August, and the Taoiseach and I obviously spoke about it in person in September.

The Taoiseach said today on Leaders’ Questions that he found out about the specifics of the spring implants only in the past couple of weeks. The Minister has not been able to recall the fact that the Taoiseach was asked a question on this in July. He said he was going to refer it to the Minister but the Minister cannot recall whether the Taoiseach referred it to him.

Again, that is not what anybody has said. I have the transcript between Deputy Murphy and the Taoiseach and I have looked at that. I became aware of the issue with the springs in August. It was not part of either of the reviews. It would appear, based on everything we have seen, that CHI and the reviewers did not know there was an issue in terms of these springs not being medical-grade springs. It was through the parliamentary questions submitted by Deputy Murphy that work was done and that was uncovered, and that happened in August - I am sorry, the work happened in July but I was informed in August.

The whole communication pattern obviously did not work because the Minister did not learn fully about the Taoiseach's question and the Taoiseach did not learn of the Minister's experience until the past couple of weeks. That is a problem in its own right.

The Minister specifically asked CHI why lists were not falling. When did he ask CHI why lists were not falling despite the extra investment that went in? When was the first time he asked and who in CHI did he ask?

I can try to get a timeline for the Deputy but this is an ongoing conversation between me, my Department and CHI. The Deputy will be aware of the waiting list action plan. We have three high-priority clinical areas-----

That is not-----

I am answering the question. This is relevant and speaks directly to the Deputy’s question. There are three clinical areas specifically called out within the waiting list action plan, and they are bariatrics, gynaecology and paediatric orthopaedics, so there is an ongoing conversation at a very senior level in the Department, the HSE and Children's Health Ireland on this. Paediatric orthopaedics, including spinal, has been a top priority right through the waiting list action plan, so these conversations are going on all the time.

I am only asking when the first conversation was but the Minister does not know the answer to that, I take it. I am referring to the first conversation with CHI as to why lists were not falling.

The first conversation will have been when it became apparent-----

I am talking about a date, roughly.

The other point to be made here is that spinal surgery can be incredibly complex. The international best practice on this indicates that quality is achieved through specialisation. My advice is that the Irish spinal surgery system is actually generalist in nature, so the culture in spinal surgery training is that you need to do everything. To what extent has this led to the crisis?

That is a clinical question, and I am not a spinal surgeon. However, it is exactly the kind of question that can be reviewed and I believe will be looked at through the upcoming external review.

The Minister did not answer. First, Mr. Nayagam is not a specialist spinal surgeon, yet he is the external reviewer. He does not have the clinical expertise to actually ask the hard questions of the expert surgeons. How does that happen?

Deputy, ask whatever questions you want, but your line of questioning now is-----

To undermine.

-----to undermine an internationally renowned paediatric orthopaedic surgeon we are bringing in to do this review. It is entirely up to you to do that. You are, of course, free to try to discredit the reviewer.

I am not.

I would suggest to you, Deputy, if I may, because you have just said something that really-----

No.

-----is not very helpful, and I will respond, if you do not mind. Mr. Nayagam was specifically identified by the chief clinical officer. It was important to the chief clinical officer that this would not be someone who was just a spinal orthopaedic expert. It was important that the totality of paediatric orthopaedics was reviewed. It was important that was done by someone who has broad experience. Of course, if the reviewer wants to bring in specific external spinal orthopaedic expertise, he can and will do that.

Can I just ask that we do not in this House try to undermine the credibility of the reviewer who is coming in to do this work?

You would have to be foolish to think that, simply by requesting that the reviewer has expertise in complex surgery, which is a qualification, I was in some way undermining that individual. I am not. It is clear that the individual who is the external reviewer in this situation does not have the same qualifications as the individuals he is reviewing. The reason I stated that is that the Minister said to me just a few seconds ago that he did not have the clinical expertise to be able to ask certain questions. Obviously, clinical expertise is very necessary to be able to carry out a review such as this. All I am asking is why we do not have an external reviewer with the necessary qualifications to carry that out.

I just want to be very clear on this, if I may. This is important, because Deputies have quite rightly spoken about trust. The reviewer does have the clinical expertise to conduct this review. I most certainly do not.

Okay. We are going to have to disagree on that. Again, on the specialist element, Scotland has a large number of surgeons who specialise in complex spinal operations. Again, Ireland does not have that level of expertise. Ireland has all-rounders. It is understood that Temple Street did not have enough focus on that expertise. Is that not an issue we have to resolve coming out of this whole review system as it stands?

That is a very fair question. The question around generalists, specialty, subspecialty as well as the amount of work and patients in that is a very important one. It is one that the reviewer will look at and provide advice to me and, in turn, to the Oireachtas on.