I will read the note on presence in Leinster House. I advise 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, a member who attempts to participate from outside the precinct would be asked to leave the meeting. In this regard, I ask any members partaking on Microsoft Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House campus.

On the minutes, the minutes of the committee's two meetings on 9 December have been circulated to members. Are they agreed? Agreed.

Today, the committee will consider maternity services at Portiuncula University Hospital in County Galway, specifically concerns in relation to identified safety issues and putting in place pathways for the transfer of high-risk patients to Galway University Hospital and other locations. We know that the care provided to 12 women and their infants at Portiuncula University Hospital has been reviewed and is currently under review but this is not the first time that the hospital's maternity unit has come under scrutiny. We know about the 2018 Walker report and that is why it is important that the health committee dedicates some time to this issue. We must be especially conscious that we are discussing reviews into the care of women whose babies have died or experienced adverse outcomes. That must be at the forefront of our minds during the deliberation. In today's meeting the committee is keen to assess how services at Portiuncula can be improved, how outstanding issues can be addressed and how we can ensure rural maternity services are protected and strengthened. These are very important questions, particularly as we move towards the development of the national maternity strategy.

To commence the committee's proceedings, I welcome the chief executive of the HSE, Mr. Bernard Gloster, and his colleagues.

Members and 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 their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

To commence our consideration of this matter, I invite Mr. Gloster to make the opening remarks on behalf of the HSE.

I thank members of the committee for the invitation to meet with them today to discuss matters relating to maternity services at Portiuncula University Hospital. These are important matters in the context of Portiuncula itself and in the wider national maternity care context. I am joined by my colleagues, Mr. Tony Canavan, the regional executive officer of the west and north-west region of the HSE; Dr. Patrick Nash, regional clinical director for that region; Dr. Clíona Murphy, the national clinical lead for the national women and infants health programme, NWIHP; and Mr. Kilian McGrane, director of the national women and infants health programme. I am also supported by my colleague, Sara Maxwell.

Irish maternity services are provided in 19 hospitals around the country, as well as multiple community antenatal and postnatal clinics. The maternity configuration involves four stand-alone maternity units at the Rotunda, the National Maternity Hospital and the Coombe in Dublin, and University Maternity Hospital Limerick. Cork University Maternity Hospital is located on the site of the main hospital. The remaining 14 services are units within HSE regional hospitals. Within the 19, there are six tertiary services, which I have listed in my statement. In the interests of time, I will move on from those. The 19 units are configured into six clinical networks within each region. In this case, we are talking about the west and north-west region. There is considerable variation in the scale of the services provided. The Rotunda has the highest number of births per annum at almost 9,000, and Tipperary University Hospital the lowest at just over 700. Of note, in 2024 two units had less than 1,000 births, those in south Tipperary and Kerry. This is indicative of many changes including demographic distribution and birth rate.

In 2016, the Government published the then national maternity strategy, Creating a Better Future Together. This is a strategy for ten years and concludes next year. The strategy was developed after a number of years of very high-profile poor maternity outcomes. These included the tragic death of Savita Halappanavar and the reports by both the chief medical officer and HIQA into maternity services in Portlaoise. The NWIHP was established under that strategy and gives national leadership towards improvement of women's health and infants, including the establishment and development of maternity services. The strategy itself contains 77 recommendations designed to ensure that all women and their babies can receive consistent, high-quality care, regardless of location. The HSE developed its implementation plan for that strategy with a large proportion of those recommendations implemented. The current programme for Government commits to developing a successor to the national maternity strategy as part of an overall programme in healthcare and women’s healthcare. I know the Minister, Deputy Carroll MacNeill, is considering approaches to the development of this successor strategy when the current one concludes next year, and she will be looking to build on the success of the current strategy and ensure a response to deficits identified at strategic or implementation level to date.

The quality and safety of maternity services is a key pillar of any strategy and the creation of the maternity network was a critical step in advancing that. In addition to its role in the direct line management of quality and safety, NWIHP on my behalf and on behalf of the HSE monitors quality and safety through a variety of metrics and process. It is clear from various reports into maternity services in the UK over the past decade that monitoring metrics themselves are insufficient for ensuring quality and safety. A number of institutions in England which were the subject of reports, such as Morecambe Bay, Shrewsbury and Telford, had met all the relevant performance measures. Therefore, NWIHP has always looked at multiple metrics and processes to try to improve quality and safety, including learning from other jurisdictions.

I have attached as an appendix to my statement the overarching framework and processes in place to monitor and advance safety in maternity care in Ireland. I am advised that there are no significant concerns arising from safety indicators across 18 of the 19 units when viewed through the relevant benchmarks. The recent outlier, as we will discuss, has been Portiuncula University Hospital. It is important to remember that in any unit there can be a poor outcome in this very high-risk specialty and each of those must be taken seriously, examined, transparently reported and responded to, and we can never be complacent about any site. What I am referring to here in the overall picture is the trend analysis that led to significant concerns regarding Portiuncula.

The care provided to 12 women and their infants at Portiuncula has been reviewed or is currently undergoing review. To date, seven external reviews have been completed and shared with families, and five are in progress. In 2023, two cases of intrauterine death occurred at Portiuncula University Hospital. Subsequent independent systems analysis reviews, SAR, of the care provided to these two women raised concerns about aspects of their care that may have had an impact on their outcome. Throughout 2024, five babies were referred for therapeutic hypothermia to treat neonatal hypoxic ischaemic encephalopathy. This represents a rate for Portiuncula of 3.82 in 1,000 births, considerably above the national rate of 1.24 per 1,000 births, based on the Irish maternity indicator system, IMIS. All five cases were reviewed by a team external to the region, led by Professor Sam Coulter-Smith, which produced five SAR reports and an overarching summary. A further five external reviews are in progress into the care of women and infants throughout this period of October 2024 to July 2025. All review teams are making good progress and it is expected that all reviews will be concluded by the end of quarter 1 of 2026.

To manage the risk and help to provide assurance on the safety of the maternity services at Portiuncula University Hospital, an external management team, comprising a consultant obstetrician, a director of midwifery and a general manager, was appointed in January 2025 to oversee and manage maternity services in this hospital in the context of the concerns raised. This team remains in place and is providing an additional level of supervision, oversight and governance to services. All seven completed external reviews have been shared with the families. Meetings have been offered to each family with the commissioner, that is the west and north-west regional clinical director, who is with me here today, along with the regional director for midwifery. To date, three families have taken up this offer. A dedicated liaison officer is in ongoing contact with these families, to ensure that any needs, including counselling and access to healthcare, for women and their babies is arranged.

In total, the 52 recommendations from the seven reviews related to five broad themes: clinical care; multidisciplinary staff training; multidisciplinary team communication; communication with women and their partners; and post-adverse-event follow-up. The overarching summary, provided by Professor Coulter-Smith, laid out four common themes: communication, governance, clinical care, leadership and clinical governance, together with infrastructure. The external management team, along with the local Portiuncula management team, has developed and is leading the implementation of comprehensive quality improvement plans in response to all of the recommendations made by external review teams to date. Progress made on each recommendation is being tracked and reported to an implementation team.

I am conscious that this unit has been through previous reports and recommendations with implementation plans. While improvements are welcome and need to continue, there has to remain significant caution as to the range and type of pregnancy that can be booked to this unit after the events referred to above.

It is the instance rate of these reviews being required, the incidents and outcomes leading to them, and particularly the backdrop of Portiuncula in what is known as the Walker report that has led to the revision to the level and type of service that can be provided there at this time.

In July 2025, the region announced that higher-risk categories of women would be transferred from Portiuncula to Galway, or to another unit of a woman's choice. This is a key element of the overall risk management strategy for the service, as advised by NWIHP. Working operational groups are in place in both Portiuncula and Galway to manage this. Extensive engagement has been undertaken with both hospital sites and with GPs to agree safe and effective pathways for the transfer and care of these women. There are defined categories of higher risk, which I have set out in my statement.

From 28 October, Portiuncula is no longer booking women with pregnancies in these higher-risk categories. The implementation team is addressing the capacity issues and the operability of this project, and is risk-assessing the impacts of the changes on all women. The aim is to achieve a smooth transition of service with minimal disruption for pregnant women, while maintaining the appropriate standard of care. Engagement is taking place with a number of stakeholder groups, including health promotion, social inclusion and Traveller health units. My colleagues will be happy to discuss the details with the committee. We are monitoring bookings to all maternity sites in the year to date, and are engaging with our colleagues in the Dublin-midlands region to assess for any impact on maternity services at Mullingar or Portlaoise.

New bookings for pregnant women at Portiuncula are down 18% in 2025, based on the first 11 months of the year, compared with the same period last year. It is acknowledged that the falling birth trend nationally is a contributing factor to this reduction, as well as the changes within the delivery of maternity services at Portiuncula. We remain committed to providing a safe and sustainable maternity service for lower-risk women at Portiuncula.

I acknowledge the concern of women who used the Portiuncula service in 2025. I acknowledge the disappointment for the people in Ballinasloe and surrounding districts. I acknowledge the disruption in confidence and the challenges for many of our fine staff in Portiuncula, and the sense of let-down that people feel when issues like this arise. I particularly acknowledge the women and their partners whose story has been and remains the subject of these case reviews. To them, I apologise on behalf of the health service. Apologies for bad outcomes and failure in health care, despite some commentary, are an important step in an open, transparent and appropriately accountable healthcare system, one which is not defensive or in denial. It is also the case, however, that when we see accelerated risk and repeated poor outcomes we have to take the right decisions, notwithstanding that they are uncomfortable for so many. I am satisfied that the decisions taken in 2025 in respect of Portiuncula are necessary and proportionate to the evidence. I want to assure this committee that we will do all possible to continue delivering the best levels of healthcare, including maternity care, in that site in a safe way into the future.

I thank Mr. Gloster. We now move to questions from members.

I thank Mr. Gloster and his team for coming here today. I thank the committee for indulging my request to have them come here today to discuss the issues around Portiuncula University Hospital. There is no doubt that there is serious disquiet about what has happened in the maternity unit there. I put it on record that I have no interest other than the safe delivery of babies at the maternity hospital in Portiuncula. Unfortunately, there has been a sense in the debate that any time there has been a challenge around this locally, we are in some way advocating less than safe practice in the maternity unit. I wish to put it on record that we are all on the same page in relation to that.

I have to say there has been utter confusion in terms of how this has been managed. I am looking around and I do not see the regional clinical director for obstetrics for HSE west north-west here today. That would have been helpful. I do not see the associate clinical director for the unit here. That would have been helpful. I am going to get into that because one of the things that Professor Coulter-Smith identified, seven years on from the Walker report, was the governance issues. When Walker made the recommendations around joint governance, there was a very clear pathway that there was to be a post with three days and two days on alternate weeks shared with the maternity unit in Portiuncula hospital. That never happened. It was not the fault of the person who did it, but their work was not back-filled in UHG so they spent an average of six hours there. One gets the feeling from talking to people that it was a box-ticking exercise.

At some point in 2024, a decision was made that joint governance would be dispensed with. Of course I have been told that the Walker report was fully implemented, which is not true. If it was, why do all the same issues arise again in 2025? If it was a recommendation in the Walker report and it was implemented, it certainly was not sustained. I want to know why the governance that was recommended by Walker was not fully supported, obviously, and was dispensed with in 2024. An interview process was held. I understand that following the first interview process, no one could be appointed as associate clinical director. A second interview process had to be held, and at that point someone who was not appointed in the first interview process was appointed. I understand that a two-year rolling-contract, which would be the normal practice, was then split between two people. I will direct my first question to Mr. Canavan: what happened with this governance issue?

The Deputy is quite right in saying that one of the recommendations from the Walker review was that we would have joint governance across the two sites, with one maternity service across Galway and Portiuncula. We appointed a clinical director to fulfil that function, but by agreement on both sides, when it was not working we stood that arrangement down. It was not working favourably for either side.

Why was it not working? Was it because there was not proper commitment? I can direct this as well to the clinical director, Dr. Nash. If it was not working, why was it not working? It sounds like the due support was not given to the person in that post to carry out that function. It was supposed to be a split post, three days and two days on alternate weeks, but that did not happen. I am on tight time but I want an answer to that.

The post was 50% clinical director, like all posts, and it was split between both sides. The candidate did have backfill. It was Galway-based.

I am told he did not.

He did have backfill in Galway but he was split between both sides. The feedback-----

Again, how much commitment did that person give to Portiuncula? Did he give the three days and two days split?

It was never going to be five days because he was 50%-----

Was it a three days and two days split on alternate weeks?

It was never five days.

Dr. Nash is saying that was not the issue.

It was agreed that he would be 50% clinical, which is Galway-based as an obstetrician, and the other 50% was split between-----

Was that time given to Portiuncula?

He was in Portiuncula every week. He was there a day a week.

That is not the question. This is the question: was he given a three-day and two-day, 50%, split?

It was never going to be three days and two days.

So it did not happen.

That was never-----

No, that is the answer.

But-----

No, that is the answer. It did not happen. I am conscious of the time. When all this broke, we were told that it related to high-risk pregnancy. No one ever disputes that people with underlying high-risk medical issues should be managed in a specialist unit. No one is disagreeing with that. I am not here for the status quo. Adverse events and outcomes happened in Portiuncula hospital, and I acknowledge that for those mothers and their babies and partners. I want to make that absolutely clear. Nothing can stay the same. We are asking for the resources that the Walker report identified, and that Professor Coulter-Smith identified seven years later, to be put in place to make sure that the 1,200 or 1,300 women who continue to deliver in Portiuncula hospital have a safe service. That is why we are here today. Regarding the confusion in communication, first, GPs were not included in the original communications. Decisions were being made unilaterally, and that is a fact. Why did that happen?

They were included.

They were not.

Well, we-----

I am a GP in the area so I know that did not happen. It was latterly. There was a sense that there was going to be a diktat sent out to GPs to stratify risk, which is not their job by the way.

The background to it is that we met with NWIHP to look at what criteria were higher risk. Once we had draft criteria, we met with GPs.

They fed back strongly to-----

No-----

Chair, can I just say-----

No. I am going to say to Mr. Nash that that is factually incorrect because I know that Dr. Annette Jennings was appointed to the implementation board latterly. That is a fact. Dr. Nash can paint this any way he wants to, but that is a fact. GPs are deeply unhappy with the way the team managed that. I am going to move on.

In the risk stratification of high risk, all sorts of stuff was coming out from the units. It was carried in the media that women who had existing diabetes who were pregnant and women who developed gestational diabetes were going to be part of the high-risk group. Then suddenly they were not part of the high-risk group. The point I am making here is that we are either doing this on the basis of safety or on the basis of capacity. Why did all of that change?

The structure that we put in place to implement the changes involved representation both from Portiuncula and Galway. Once the team started meeting in the middle of the year, they were considering all of the various criteria, what was appropriate and what was the correct way forward. The decisions they were making as we were progressing towards October implementation influenced that.

Finally, because I am running out of time here, I want to ask about the evidence base. I asked why the clinical director of obstetrics for west and north-west is not here is because he should be here. At a meeting with GPs about two months ago, his exact words were that there was "no evidence base" for much of the movement of the high-risk groups that have been identified in Mr. Gloster's document here today to Galway. They were his exact words. Dr. Nash was at that meeting.

Can I interject to assist? That is a very expert, specific question and I will ask Dr. Murphy to respond.

Briefly, please, because we are over time.

It is a very serious question.

This is a very serious question.

Deputy, you are over time. If you want an answer, we will take a brief answer now.

Fine. Thank you.

We will take a quick answer, if we can.

I can answer that. Women with a BMI of more than 40 have an increased risk - up to three times more - of cerebral palsy. Women aged more than 42 have an increased risk of stillbirth and perinatal mortality. There are many, many studies showing all of this.

So why would the clinical director-----

Deputy, you are out of order.

I just want to know why the clinical director would come on and say that there was no evidence base for the movement of these women.

Deputy, you are out of order. We are trying to get an answer to your question.

That is a direct contradiction of what he said at the meeting.

Deputy we are trying to get an answer.

I am fine. I yield.

Deputy, we are trying to get an answer to your question.

What has been done, obviously, is different from what has been done previously so it is in that context that those comments were probably made. The evidence and the literature is quite clear with regard to the high-risk women that we have identified.

We can tease this out in a further round of questions if we get to it.

I thank all of the witnesses for being here today. I will begin by acknowledging, as the witnesses have done, the women, their partners and the families that have been involved in these and previous reviews. I also want to acknowledge the staff at all levels in Portiuncula. This has been a really difficult and worrying time for them, particularly around the future of these services. I also want to acknowledge the national maternity review which, in terms of overall care experience, put Portiuncula just second to Kerry. It was extremely strong in terms of levels of care and really positive experiences and it is important to note that they were births from February and March of this year. I just wanted to put that on the record.

For me, one of the most important things we can take away from this meeting is the future of maternity services at Portiuncula. Is it the intention of the HSE, and of Mr. Gloster as chief executive, that on implementing all recommendations - that implementation is under way - we will see the full restoration of maternity services at Portiuncula and not just for those deemed low risk? I ask that because in the summary version of the report on the back of the five external reviews, a lot of what is mentioned under the four headings of mobile phone coverage, the bleep system, access to interpreters and greater attendance of staff at training can be put in place, delivered and implemented very quickly. I was actually surprised at the level of the recommendations within the report on the back of the five external reviews because much of it can be done if the will is there. Is it the intention to fix what needs to be fixed, implement the recommendations from the reports and then seek to restore maternity services at Portiuncula as before?

I have no difficulty in answering that question, as I have for Deputy Daly several times. The only decision which I approved in 2025 was based on the evidence of the conditions as well scrutinised and presented to me. Absent those, if that was not the case, the decision would not have been made. If those conditions were to change into the future, of course we can consider what can be done. However, there are two significant factors that I would say I and, indeed, my successor, would have to consider. First, as Deputy Daly quite rightly pointed out, and I have referred to it several times at this committee, the Walker report arguably was technically implemented but as I have said, technically is no good if it is not sustainable and it clearly was not sustainable. If it is sustainable and if we are able to implement recommendations and they are sustainable, then I have no doubt that the maternity strategy the Minister will produce for the next phase will consider that for all 19 units. There will be no disproportionate or disfavourable decision made on Portiuncula because of the past. The provision of services will be based only on the clinical evidence of what is available and what it is able to do today. I can say to the Deputy that if the conditions that were presented in 2025 were not present, we would not be having this discussion. If those conditions change in the future, then of course there is always room for a discussion.

Okay. I welcome that because previously at an online meeting I was told this decision was made and it was made for the future, which I thought was very odd in terms of the whole point of doing the reviews and implementing the recommendations. Obviously a key issue has been the over-reliance on and overuse of locum consultants. Again, in the summary report that has been put together on the back of the five external reviews, one way of tackling this was to create joint consultant posts and senior clinical roles across the group, as has happened in other regions. Is that something that can be achieved?

I will take the region's view on the achievement of it. There is certainly no obstacle, nationally, to whatever the region requires to support the women and children who are using maternity services in the whole region. I would say to the Deputy, in all sincerity, that it is not a question of a post. What we find in parts of the healthcare system is that no matter how many posts we approve, attracting the highest level of training and specialist interest to a distribution of 19 units is increasingly difficult. While Professor Coulter-Smith was quite correct in his observations, I would not want anyone to leave here thinking it was about buildings or phone coverage. Absence of expertise in neonatology and other things are all critical to modern-day delivery of complex pregnancy. We know the demographic distribution of pregnancy and the complexity factors have changed nationwide because of that. I would not want anyone to think it is the absence of me approving a post. I will approve any post that needs to be approved. The ability to fill it and sustain it, rather than locum it, is a different factor.

Two of the posts in Portiuncula are split between Galway and Portiuncula, 50:50. They do alternate weeks between the two. Two people were appointed but they both left. Somebody was appointed recently and the second half of the post has gone to be advertised again. It is hard to keep it sustainable because the sites are the bones of an hour apart for the individual doing it. That said, we are committed and part of the outcome of the Walker report was to have a split post and we have those two posts in place.

In the same report, it was strongly recommended that there would be a review of maternity services and how they are delivered across the country. Is a wider review of all maternity units going to be done?

My colleagues from NWIHP can fill out the details if necessary but the two steps essentially were based on the maternity strategy, which came out almost coterminous with the Walker report. Based on the maternity strategy, the Walker report and all of UK reports, the first thing was the establishment of NWIHP to establish consistency across the country and support for development and improvement. Portiuncula was not the only unit that required improvement; I want to be clear about that. I have discussed this with the Minister, Deputy Carroll MacNeill, and the next phase of that review of the 19 units across the country, based on the totality of the evidence available, will inform the next maternity strategy that she is considering.

She will advance that in 2026. All of that will be taken on board.

In regard to women not having their babies in Portiuncula and going to UHG, which sometimes is a considerable distance with heavy traffic, many of us know how difficult it can be to get into Galway city. Mullingar will also more than likely be used. In his opening statement, Mr. Gloster said the implementation team is addressing the capacity issues and the operability of the project risk assessing. Has a risk assessment of UHG and Mullingar been undertaken to examine capacity, staffing vacancies, which in terms of midwives are quite high, certainly in Mullingar? I have the figures for Mullingar but not for UHG.

I will ask the two clinical directors to address that.

As part of the implementation of the transfer and the higher risk, we have a committee in Galway and in Portiuncula looking at it. The key request in Galway was additional theatre access, which has been provided because women being transferred there have a higher caesarean section rate. We have given additional theatre access for gynaecology to allow the capacity for maternity. The inpatient wards, the antenatal, labour and postnatal wards have capacity. Ten years ago, they would have delivered. We are expecting between 250 and 300 women to be transferred. They have the capacity to manage that.

Once again, the witnesses are most welcome. I applaud Deputy Daly for inviting them. What struck me the last day Mr. Gloster was here was the commentary around the question I asked about services at Portiuncula University Hospital. He referenced that it was new and referring high risk cases had not done this before. I thought that was compelling in the context of taking preventative action to make sure there was no repeat of any loss or injury of any baby. Those of us who took the time have met some of those mothers who tragically were not able to leave the hospital with a baby. That is not a nice place to be. I am glad the Cathaoirleach referenced that fact that, behind this discussion we are having today, there are people who are grieving and are emotionally challenged as a consequence of happened. The decision that was taken at the time, as was mentioned in the report, certainly caused local anxiety or annoyance and all those things that come with what was perceived to be a downgrading of services. Based on what he said the last day when he referenced something like significant and out of ordinary circumstances, on balance the referrals were made for good reason. The circumstances were breaking national and international standards. That was enough for me to support the referral of high risk cases elsewhere. I know the external management team is in situ still. The review is expected to be completed by the end of January. Let us hope that review team on referrals is getting us to where we want to be. What we want out of all this is that Portiuncula University Hospital will be a centre of excellence. That is what Mr. Gloster is striving for and that is what we are pleading for.

I have three questions. As I mentioned, it was in the report that the review committee will have its findings completed by the end of January. When does Mr. Gloster anticipate, be it a gut feeling or an expert opinion, that we will be in a situation to have normal services? When will high risk cases be able to attend Portiuncula University Hospital again for delivery of their babies?

I am sorry, I thought the Deputy Roche was giving me the three questions first. Again, to underscore, he made a very appropriate reference to what this is all about. I can never say enough to the women he referred to about how sincerely sorry I am. It would be skirting around it to say otherwise. It is difficult to anticipate. I did say we had not done this before. We will have to evaluate what it is and what its impact is on safety indicators, or not, and what its impact is on incidents. The fact we have not done it before probably is not of itself more significant. I have been in the health service for nearly 40 years. Looking back, there might have been reasons we should have tried it before in different places. It is the best evidence available. It would be unfair of me and to the people I have apologised to, the people of Ballinasloe, the staff in Portiuncula, to try to put a time frame other than to say what I said in reply to Deputy Kerrane. If the conditions that were present for the decision we made in 2025 were to change substantially, there would not be a difficulty in making different decisions. However, it is impossible to anticipate when that would be because of the scale of a repeated problem, even when we believed we had implemented the Walker report recommendations. That is the fundamental issue. The context is whether we can get to a level of sustainable specialist skill, not dependent on locum, that could give good outcomes. I do not know when that could be. I hope that the maternity strategy will help us to identify that question.

I thank Mr. Gloster. Communication was referenced twice in the report, probably in different contexts. I am trying to evaluate whether it was a case of lack of communication or were people not willing to communicate? How can we be sure that if we are dealing with the same individuals, regardless of who or what their position was, that they can bring themselves to do that better in the future?

Communication deficits in healthcare incidents, healthcare studies and healthcare management usually cut far deeper than whether somebody just did not or was not willing. Communication, when it is described in a report like this, is a culture that builds up. It becomes an acceptable way of doing business. Bad communication or no communication just become part of the life of a part of the health service and in a unit like this. That is what the experts were pointing to. It is a fundamental cultural issue. It can happen over time. People may not be aware of it. They do not any deficit in it. However, clearly, communication deficits on decisions such as to move to C-section decisions or to move to consultant on-site presence for a complex delivery were part of what led to poor decisions.

Since this situation occurred, the Minister displayed absolute and emphatic honesty with ourselves as public representatives right across the political divide. What she wants, what Mr. Gloster is looking for and what we are pleading for, as I said earlier, is normal services to resume. Right now, as the external management team has been in situ for a year, I trust we are getting to where we want to be. That is what we are all asking for. One obstacle is that old habits die hard. If people are not fully willing and engaging to make sure this becomes a centre of excellence, we might have a more delayed delivery of the service.

On her first day in the job as Minister, instead of briefing her on the health service, I had the dreadful task of briefing her on Storm Éowyn and Portiuncula.

The Minister got into her car and went to Portiuncula and met the women and the people involved. From that basis, she was very clear that we have to make it the best it can be for the women so that they are able to safely go there and we can be assured about that. We also have to make it the best it can be for the people who cannot go there right now and we have to make it the best it can be for the future. That desire has informed all of the decisions.

As I said at the start, I am quite conscious that there have been 12 reviews of the place in respect of cases of people whose babies either died or were adversely affected. I also know there are really serious concerns in the region on the part of people who are pregnant and who have concerns about safety and access to services. Locally, people have concerns that the long-term intention of the HSE is to close the maternity unit in Portiuncula. Can you confirm that the HSE does not intend to close the unit?

I can absolutely say that the decisions that we made in 2025 were made on the basis of the incidents, the context of the incidents, the trend and the risk. They were made in the best interests of women and their partners and infants, and the care during pregnancy. I can absolutely and categorically say that I have not received one ounce of direction, discussion or hint from the Minister, the Department or the board of the HSE to in any way alter or reconfigure services in the region, including Portiuncula, and I would be very clear about that.

Is closing the unit off the table?

A unit would be closed if it continued to dysfunction and be unsafe, and if it did not improve then one would consider what to do, but I do not believe that is going to be the case because I believe in the intervention we have made, as difficult as it has been. I also take the core point made by the Deputy, Dr. Daly. His core interest today is my core interest. For the women who continue to go there and be booked there, we have to make it the best it can be for them and their children. That is what I am determined to do and I believe that the Minister is going to make sure that continues.

It is crucially important that we strengthen the network of services, particularly in rural areas. What is the status of the review into similarly sized maternity units? When do you expect the review on 11 smaller units to be completed?

Perhaps one of my colleagues will respond.

There is not a review per se under way. The review that was referenced in the Coulter-Smith report is the one that the CEO addressed earlier in the context of the Minister and looking at the successor to the national maternity strategy. Has the Cathaoirleach a specific note about a review of the smaller units?

My understanding is that there was a review taking place into services more generally and into the smaller units.

Maybe the best help I can give is that before we had NWIHP there was no review, tracking, benchmarking or monitoring. We now have. We publish our reports. We publish our incident maternity reports, quality indicators and everything for people to see. This year is the first year that we named all of the units against the indicators. That is an active and ongoing review. The fundamental review, which will be the challenge for 2026, will be for the Minister to consider how to approach and what reference point to use to approach the next phase of the maternity strategy for Government. That ultimately will be the decisive review.

The summary review that was published in July said that "units of this size find it difficult to attract permanent members of medical staff and rely heavily on locum consultants". Has there been any significant increase of decrease in staffing levels this year?

In medical staffing, at the moment we have two locums in obstetrics and two in paediatrics whom we are going out to permanently recruit. It is a struggle in all our smaller units to recruit and retain consultants. We have five maternity units in our region. Three others are a similar size to Portiuncula. It is a challenge to recruit and retain.

It is important to say that it would not be any different for obstetrics as it would be for healthcare in all of our smaller hospitals, so it is all specialties. People who train now to the standard people train, with international fellowships, will not and do not want to work in a single small site. They want to work across a network of specialty.

Do you agree that downgrading a maternity unit with no clear timeline about reintroducing services will make it even more difficult to attract and retain staff in the current situation?

My professional opinion on that is, if we are attracting staff to work in both Portiuncula and Galway, or Portiuncula and other units, it will be much easier.

How long do you expect the default transfer of high-risk patients to other maternity units in the region to continue?

Again, I was very careful because the worst thing I could do is give the public a false hope or a false expectation. It is impossible to put a date on it. We will evaluate how the transfer of high risk went, and we will evaluate the quality of the women who continue to use Portiuncula. On the basis of that, we can see what the future decisions are but it will continue for some time.

Are we talking months, years or until the end of the decade?

If you go back to the origins of why Walker happened, Portiuncula now has been on and off the consideration radar for almost 13 years. It would be the most awful thing for me to do to say to people that I could just put a time on it to get out of answering a question. I cannot.

We are pressing the question because of how important this is, the urgency here, and the need to strengthen and open these services. I can move on. I understand that most women are being transferred to Galway. What additional supports or investment have been provided to increase the capacity there, in that instance, where in the long-term we are going to be transferring people? Galway's maternity unit is already overstretched and the hospital is difficult to access, as referenced earlier. What additional investment and supports are going to happen in Galway in the context of this happening for the long term?

The principal requirement in Galway, as Dr. Nash mentioned earlier, was for additional access to theatre. That has been provided and is being protected so that is in place. There have also been requests for additional staffing. We have provided some of that staffing and we are looking at the remainder of it.

How many staff have been requested and how many filled?

I do not have those figures off the top of my head but, relatively speaking, we were not talking about significant numbers of staff for the unit. We also took the decision earlier on that the transfers would take place while that was being dealt with.

Can the HSE provide us with the details of the staffing levels requested and filled?

We can do, yes

Can the HSE provide the details of the posts that were asked for, those that were filled and the timeline for filling the remaining posts?

Yes.

In this context, we will need to strengthen the other services if we do not have a clear timeline.

Very clearly, Chair. Yes, of course we will do that immediately after the committee.

In the context of the new regional structures, the role of the national women and infants health programme has been outlined. Is the funding being managed centrally or by region now we have the national women and infants health programme?

Each region operationally manages its own services, hospitals, community services and maternity services. What the national women and infants health programme does and will continue to do, the same as the cancer control programme and whatever programme, is to devise the national plan, create the training and skill set to enable the plan, and then performance manage and assure, at a national level, that the plans are being implemented and working. It will continue in a very strengthened role.

Is the funding decided at a regional level?

The day-to-day operational funding is allocated to the region as part of the service plan.

Is the policy base done at a national level?

All the policy and the monitoring and assurance of the policy are done at a national level.

That is great. Thanks very much.

I am glad that we are having this hearing. I am also painfully conscious that there are families who have had adverse outcomes, that the staff have been through a very traumatic and very upsetting time, and that there is the uncertainty about what the direction of travel is going to be. I remain very confused as to why we are here today because, as Mr. Gloster has said, this is an issue that has been on and off for the past 13 years. We have had the Walker report, the national maternity strategy in terms of all those recommendations, and there was talk about the metrics that were met and yet there were still issues. Why are there still issues in Portiuncula? What makes Portiuncula different from other maternity units? Is it because of culture, staffing or leadership? What is it? That knowledge is crucial to deciding the direction of travel into the future. I would like to hear from Mr. Gloster, as head of the HSE, as to why he thinks this is the case.

I will give the Deputy the best assessment that I can give, and I think there are two parts and it goes back to the start of the committee. First, I think, as an organisation and as the national health service, we came up short on the side of the sustainability of implementing recommendations. We came up short on those and I would be absolutely lying if I said anything different. That is not to say we had bad people who went and deliberately did bad things. Recommendations from reports are notoriously difficult to follow in a sustained way. That is the first reason. That is our shortcoming side.

The second side, and I hope that members of the committee will accept my bona fides on this, is that a sustainability question arises as healthcare modernises about where we can have the number of specialists needed to deliver the types of services needed in the number of places we want to deliver them and do that at a safe level. For example, model 3 hospitals do certain things model 4 hospitals do not and so on. This is the argument that has bedevilled Irish healthcare. The Deputy will have seen the steps the Minister had to take yesterday to take corrective action in the mid-west about something that happened 15 years ago. It is a feature of how modernised healthcare has come and trying to keep pace with it everywhere. However, we as a health service, and I, as head of it, have to accept that there is a responsibility on us organisationally for not reaching the level of sustainability we should have or not calling it sooner when we could not. That is on us.

With sustainability, there is responsibility or the lack of anyone taking responsibility, if it is a locum-led model, to put it bluntly. What is the HSE doing about that? Aside from obstetric services, we have agency rates of 20% of those on the payroll in Mullingar and Bantry. It is smaller in Portiuncula. What is the HSE doing in that regard? It is a reality that level 3 hospitals outside the main teaching hospitals are going to be less attractive to consultants. What specific action has the HSE taken or is it taking to address that?

Exactly what we are doing outside the specialty of maternity is what we are trying to do in the specialty. It is through the creation of a network of sites. We try to attract specialists to work in a multisite network rather than a single place and that has certainly proven, in some cases, to be helpful.

The Deputy is right that our dependency on agency staffing, as we have discussed in this committee previously, is high, but it does not always result in the types of safety indicators and issues we have seen emerge cumulatively over 2023 and 2024, after having apparently improved in 2021 and 2022. That relates to the sustainability question. It is more than the locum issue. It has developed to a level of reliance on systems, culture and processes that are not safe or sustainable and that did not happen in other smaller units. We know that from the trend indicators in other units. Incidents happen in every maternity unit. It is part of the risk of that speciality, but the rate and trend of them, compared with the history of Portiuncula University Hospital is fundamentally different.

The consultant obstetrician, the director of midwifery and the general manager were put in place at the start of this year. Are they permanent roles or are they temporary? If they are temporary, how long has that arrangement been in place?

It is a temporary assurance arrangement that went in at the start of the year to support the people on the ground. It has continued effectively full time since in many respects. I am grateful to those people for coming back into service to do that. It is not easy to get people. However, we made a conscious decision, because of the decision on the transfer, to keep them for a longer period than originally intended to give us that added assurance Deputy Daly referred to, for the women who continue to go there. I want to be assured, apart from the dreadful decision that had to be made and the awful trauma and upset it has caused many people, that not only the decision, but the service works for the women who continue to go there.

Mr. Gloster cannot give a timeline for when there may be a change.

No, I cannot.

At what juncture, or upon which metric, will a decision be made to resume the service that was in Portiuncula? What is the indicator that will mean a decision will be made to resume normal service?

Dr. Murphy, as a specialist, may want to come in on this but, from a corporate governance and management perspective, there are two junctures. The first is to establish whether moving the higher risk cases and improvements being made in the unit for the women who continue to go there give us a reasonable level of assurance around incidents and outcomes for women. I take it that, already, the care survey that was referenced shows women are happy with lots of aspects of care. That is the first juncture.

The second juncture is whether the level of speciality available on the floor of the units, whether that is obstetrics and gynaecology or paediatrics and neonatology, is at a level comparable with any of the other 18 units that currently operate to safe standards. They are the two junctures from a corporate governance point of view. Does Dr. Murphy have anything to add?

Not really, but things like leadership and proactivity on the site would need to be seen. However, I agree not having a timeline for that is correct.

In my last few seconds I will ask a question, although I may have to wait until the second round for an answer. An audit of the home birth service was undertaken in 2025. It was not specific to Portiuncula, but for the whole country. However, as Dr. Murphy and Mr. McGrane are here, I want to understand where the HSE is with regards to home births. There is significant concern about the policy of the HSE at the moment - some women want home births - and the risk to patient safety.

We will take a quick response to that and we can come back to it if necessary, but we will take 30 seconds.

We have home birth services in the country. Unfortunately, there is regional inequality in it. Part of that is due to the specialised services required. The role of self-employed community midwife is not one many people want to take on. There is quite a lot of responsibility and it is quite an onerous task. We recognise that some areas, such as the west, do not have as wide a spread as others. From the Saolta report, there also does not seem to be as high a demand in those areas. Sometimes the two things go together. The findings of a serious review of the mid-west services are being considered with regard to what else will happen there.

I thank Dr. Murphy. We can return to that question if necessary.

We will now take a five-minute break and we will return with Senator Rabbitte, Deputy O'Hara and then Senator Scahill.

I thank the Chair for facilitating me in substituting for Senator Costello. I too am conscious that there are a lot of people watching our commentary today so language matters. I appreciate that in what I will say. I was present in 2018 when the Walker report was launched. I was in the room upstairs in Gullane's Hotel. It was not launched in the hospital, but in Gullane's Hotel. On the night in question, I recall asking whether it was really thought that having one person over two sites would work. That was my little contribution. I am not a clinician but I have learned a lot over time. The circle goes around and we are unfortunately still going around the circle on this story. I have one question. I thank the witnesses for coming before us but there is a person missing, the clinical lead for obstetrics for the west and north west, Professor John Morrison. He was there at the time and led us into this. I believe he needs to lead us out of it. His voice is missing today. Can Dr. Nash explain why Professor Morrison is not here? I have sought for him to come here to answer that question regarding two sites and one person numerous times. Why did it not work? What learnings can be taken so that it can work?

Professor Morrison reports to me. I have the overall clinical governance responsibility for the region. That is why I am here today.

He has responsibility for obstetrics, however. We are talking about maternity services. We are all here to understand. The Walker report specifically referenced governance training and communication. Professor Sam Coulter-Smith's report mentions the same things again. It just keeps repeating. What is the learning? The best phrase going around this establishment, Leinster House, at the moment is that lessons have been learnt. What lessons can be learnt to reassure people? Safety is first. It is paramount. Let us be clear about that. However, everybody wants to mind their own patch. That is why all bar two who are present today are from County Galway. We want to protect our maternity unit on our patch. While we appreciate there is a great one in Galway, we have asked for an audit saying where Ballinasloe sits. Perhaps Dr. Murphy can answer this. In the review of all the audits of all of the maternity services right around the country, or even just those in the west, where does Ballinasloe sit?

Looking at the Irish Maternity Indicator System, IMIS, report for 2024, where Ballinasloe and Portiuncula sit in respect of therapeutic hypothermia is really high. It is off the charts. If we waited until the end of that report, we would rightly be criticised for not acting sooner. That is the reason we are here today. It is very high and off the charts. The equivalent of one in 215 babies delivered require therapeutic hypothermia. The expectation nationally is one in 1,000. There can be variations. We look at that closely year on year. Our usual method of communication if somebody is a little bit high one year is to ask what can be learnt and what can be done. We are heavily involved in learning events throughout the regions. However, the level here was extraordinary. As has been pointed out by Deputy Sherlock, Portiuncula rates very highly with regard to clinical care, how people are made feel and how people are valued. That is understandable but, with regard to safety, it was an absolute outlier. Other units may be outliers in other metrics but this metric is very significant. Babies requiring therapeutic hypothermia are at risk of cerebral palsy and all of that. It is a lifelong condition. If somebody has a postpartum haemorrhage, that is not a nice thing to go through but that person will generally make a good recovery. This metric trumps a lot of the safety metrics. That was the concern.

I thank Dr. Murphy for giving us a good and in-depth understanding and answer to that question. The next question I am going to ask relates to due diligence. If the hospital is no longer taking the high-risk cases, what due diligence has been done with Galway University Hospital and the hospitals in Mullingar and Portlaoise? When a constituent comes through my front door, says they are in the high-risk category and asks about where they are going, I want to be able to say I asked that question and know what due diligence has been done with that hospital. We need that until the metrics are in the right zone again.

There are two parts to that. It is a very appropriate question. On the first part, the metrics for the 19 units are our reference point. That is where the outlier of Portiuncula versus the rest arises. That is where Galway and Mullingar appear different. I made passing reference to the second part within the statement. What is happening in Mullingar is being monitored to make sure there is no adverse impact or overburdening on that unit, causing another problem. Things are happening at the basic level. For example, theatre time in Galway has been reorganised and rescheduled. Gynaecological theatre has come out of where it traditionally was to create theatre capacity for C-sections and other surgical interventions associated with birth. Quite a considerable amount of work has been done. The difference since the time of the Walker report is that the region has to go through its due diligence. I then have the national women and infants health programme, NWIHP, which is my assurance. That has full access to scrutinise the decisions and actions in the region in order to assure the system. We did not have that level of assurance heretofore.

I will expand on that if Mr. Gloster does not mind. Mullingar and Portlaoise are outside the region. The advantage of Portiuncula was always that it had a good midlands spread into Offaly, north Tipperary and across.

What is happening there with the due diligence with exactly the same criteria, with emergency access and theatre access?

On the monitoring of any impact on Mullingar, it is the regional executive officer. That is Mr. Canavan's counterpart for Dublin and the midlands. She has the appropriate capacity and support to make decisions if they need to make amendments there. So far, we not seeing that type of impact. That is the value of NWIHP, looking across the six regions and the 19 units. It makes sure we get ahead of that.

I have one last question for Dr. Murphy. We know a new national maternity strategy will be developed, as it is in the programme for Government. My question has a "Yes" or "No" answer. Is the HSE looking to reduce the number of maternity services around the country and is Portiuncula at the slight edge of that? This is a concern for a lot of people.

No decision has been made on changing or reducing the number of units across the country. What NWIHP is doing at the moment is - in view of the complexity and the change in demographics since the start of the maternity strategy - looking at what services are available across all the units in the country with regard to maternal medicine. We are doing this review within NWIHP. In many of the hospitals, we are seeing positives with regard to links with cardiology and neurology in various sites. There are some positives in some units and other gaps, so we are doing a type of gap analysis on that. The focus is on how best we can serve the population we have.

I want to start by acknowledging all the women involved in the reviews and the staff at the hospital who do a tremendous job. This is a very difficult situation for everybody concerned. It has caused a lot of stress and worry in the local community, particularly for expectant mothers and their families. I am sure everyone is well aware of the concerns that people have in terms of what has happened and what it will mean now and in the future for mothers.

Regarding how the decision was arrived at, who made it and how did it come about? Obviously, it was not one of the recommendations of any of the reviews.

The responsibility for the decision rests with me as regional executive officer. I arrived at that decision on the foot of correspondence I received from the clinical director, Professor Morrison, and from discussions with Dr. Nash, engagement with NWIHP, the HSE at national level and with the Department of Health.

What specific data was produced to support the decision?

The basis for the decision was the reviews that were already under way at that time relating to cases that had arisen in 2023 and reviews that had arisen over the course of 2024 at that time. By the time the external management team was installed on 27 January, a further case had arisen in 2025.

Were there quality impact assessments and risk assessments carried out on the impact the decision would have?

There is no doubt that the quality of the care provided in the cases that were under review was under question from the preliminary assessments that have been conducted, so there is no question about that to start off with. The risk assessment process is an ongoing one because we have been asked about this on a number of occasions. The implementation team comprises people from Portiuncula, Galway and the broader community as well. The team is assessing the steps it is taking as it progresses.

What specifically is the ongoing risk assessment looking at?

A range of issues are considered. The issue of transport was brought up earlier. Consideration is given to the question of whether there a transport issue or a timing issue for people to get to Galway and how could that be addressed. There is a range of different types of risks that might arise and different suggestions and solutions being put in place.

Have any of those assessments been completed yet?

The implementation team is continuing to work and take decisions as it progresses. From the October date, bookings for the higher-risk cases were going to Galway at that point, so the decisions would have been made as the work was ongoing.

In terms of the different areas that are being looked at as part of the risk assessment, have there been any outcomes yet?

I am not sure I really understand the question.

The assessments that are being carried out in terms of the impact that this is going to have on people, does the HSE have data in relation to this that it can publish?

No, not yet. The principal reason is the care and time taken to make the decision as to the categories of what constituted higher risk. There were already high-risk bookings to other sites. There was the higher-risk piece. The time and care taken on that and the assurance of that by NWIHP nationally, on my behalf, was the process, if you like, in decision-making. For the actual bookings, the change of date of the bookings of the higher-risk, commenced in October. Those pregnancies would not have yet concluded to the point that we would have an evidential basis-----

I know but I am asking-----

-----to say what were the outcomes and what were the outcomes of the risk factors such as transport and people being discommoded, so it will take a couple of months.

To give the Deputy some assurance, I can say that we made the decision this year to name the 19 units on all the indicators we look at them by. We will follow that by publishing the outcomes of anything other than individual patient personal information. We will publish them in terms of our assessment of the impact of this decision.

I am asking whether in advance of this decision being made, or in advance of the decision being implemented, any specific risk assessments or quality impact assessments carried out?

All of those factors are considered by people at both clinical and managerial levels. It goes right across the range, from public confidence to things like the basics of transport and getting there to actual clinical care. I say this with the greatest level of respect, the fundamental evidential basis of the decision made in 2025 was the out-of-kilter rate of those requiring therapeutic cooling. That rate was so significant that assessment of other factors or contingent factors becomes very secondary to that. That is the fundamental evidential base. What the Deputy is asking is not possible to assess for about six to nine months. It will be possible to assess then and the decision will have to be considered again, once that evidence is looked at.

Regarding the restoration of high-risk cases to Portiuncula down the line, Mr. Gloster mentioned this might happen if the conditions were to substantially change and if there was not such a dependence on locums. Will Mr. Gloster be very specific on what needs to be in place for services to be restored and what would make it sustainable?

I think I said earlier to one of the Deputy's colleagues that the two fundamental factors are the reverse of what led us here. The first factor is to consider whether this unit is capable of being staffed and of operating to the same general trend of outcomes as the other 18 units in terms of key safety indicators that led to the decision. An obvious part of that assurance would be the sustainable regular availability of expert clinicians in obstetrics, paediatrics and neonatology. They are the junction points but putting those in, having been through the Walker report, means that we need to make sure that this is sustainable in terms of the quality of the improvement. They are the junction points that would inform the future.

At this point in time, how does Portiuncula compare with other maternity units in terms of those assessments?

I will cover what I said in my statement and I hope people do not think it is in any way patronising. Portiuncula does many things very well. There are many very good people working in all grades of healthcare there, including in the maternity unit and I recognise this. Nobody is turning up there to do a bad job. My job is to make sure that all of the conditions are right to keep the women safe and happy, and likewise with the staff to enable them to continue to deliver the care to the population. For the higher-risk group, when we know what the impact is, we will look at that. Unfortunately, today, when it comes to the fundamentals of the cooling requirement for babies - and we can debate as to why or how - Portiuncula was at a level of safety requirement that nobody could stand over.

I thank the witnesses for coming before us. It is very important to have this discussion. I also acknowledge the staff in Portiuncula University Hospital for the great work they do. I have spoken to many locals in Ballinasloe and lots of families who have used the services in Ballinasloe. The resounding message is that the staff are wonderful and people are really appreciative of the work they do. The experience in 2025 has left a lot of staff members feeling that the finger has been pointed directly at them. It is good to put on record and acknowledge their work.

The opening statement acknowledged that Portiuncula has been subject to previous reports, recommendations and improvement plans and yet we still see similar problems emerge. Why have the governance, communication and clinical failings identified previously been allowed to re-emerge?

It is not a question of them being allowed to re-emerge. Earlier, Mr. Gloster pointed out that when we look at instances that arise in healthcare settings, communication features frequently as one of the issues that is the primary or key causal factor. It is not just the quality of the communication. Sometimes it is also the timing of the communication. There are many different aspects to it. The disappointing piece for us was that the Walker review was completed and not surprisingly communication within and between teams and between clinicians and patients was found to be lacking or of concern. That finding in the Walker review was not surprising. We implemented all of the recommendations. We had a process behind that and we had that process independently verified. HIQA also verified it. All that was relatively shortly after the publication of the Walker review. Since then, we have seen slippage. We have seen this arise with the key issues around communication such as the quality and timeliness of communication, communication within and between teams and communication with patients. It is not a question of allowing it to happen. It is a constant source of work within the clinical setting that one is always trying to improve communication.

We were told the Walker report was implemented fully. It was either not fully implemented or it was not maintained. Other reports are ongoing. What assurances have we that we can have faith in implemented recommendations, faith that they will continue and fail-safes to ensure they keep doing that? Are they in place?

The focus of the external medical team that has been in place since 27 January has been very much around ensuring that the issues that arose are being addressed. A very significant part of its team is spent on education and training of existing staff in Portiuncula. The team is also leading on the process of making sure the recommendations we have received so far from the reviews that have been completed are being implemented in a systematic way. The timing of the external team staying with us will, hopefully, give us enough time for them to be in place for the remainder of those reviews to be completed. The team will also oversee those recommendations. It is really important that we do not look for certainties. We must look for the best evidence we have that we are making the best efforts we can to ensure issues like communication are addressed and are being addressed on an ongoing basis. It is not a job that can be done today and then parked. It is a job that must be done every minute of every day.

Obviously, the important element of this is the clinical well-being of expectant mothers and their babies. I understand that we have been told that and this is much of the basis for many of the decisions that have been made. I come from north-west Roscommon. All of my family were born in Portiuncula. It was the closest maternity hospital to us and the one we could get to quickest. Our options now are Galway, Castlebar and Sligo. Regarding the maternity experience survey that has just been published, the witnesses are telling us that if we go to Galway, women will have a safer birth but in terms of this report, the experience in Portiuncula was better than the experience in Galway, Mayo or Sligo. I do not have the information about Mullingar with me. What assurances do people in the area have that where they are being sent to will be as good or to the same standard they are expecting?

We have a network of care for maternity services led by John Morrison that looks at all the metrics across all our five units to provide assurance about quality metrics and safety metrics, which are overseen nationally as well. That is the key enabler providing assurance about all the services in Portiuncula and the other four maternity units. With the implementation team we have in place for the transfer of higher-risk women, we are very closely monitoring the two units - Portiuncula and Galway - to see expected and unexpected impacts of this transfer of women to Galway as part of our ongoing risk assessment about both sites.

That is with Galway but are there measurables there for Castlebar and Sligo?

Yes. All our sites are monitored to the same extent by the networks of care they provide. We are monitoring all the key safety metrics and they are also overseen nationally. The networks of care report to Mr. Canavan and me on an ongoing basis about specific issues in any of our maternity units that need to be addressed.

Going back to the full restoration of services, Mr. Gloster gave us an idea of what needs to be met to reverse the decision - staffing, key safety indicators and sustainable availability of specialists. Does he see this being a phased restoration? Does he have any timelines?

I am not being evasive or coy. I would hate to meet a woman on the streets of Ballinasloe in two years' time who would say to me "You said". I cannot put a timeline on it. The National Women and Infants Health Programme and the region but particularly the National Women and Infants Health Programme would have to assure me that the level of clinical service available, the sustainability of that and the implementation of the key recommendations of the various reports in a sustainable way are all present to reconsider the booking profile in Portiuncula. That is the timeline. It would be so wrong of me to say that to the Senator. It would just be wrong. I did not go into this decision with any view of Portiuncula or of downgrading anything. I would come back out of this decision as quickly in the same context.

Does Mr. Canavan share the same views about restoring the service in Portiuncula?

I do but I have to say that my focus right now is the safe transfer of higher-risk cases and that has to be the focus. We need to make sure we get that right and that we deal with any risk issues that arise and practical issues that would arise in that context. That is where my focus is right now.

My sympathies go out to the women and families adversely affected by the care because it is really traumatic for them to go through a difficulty that arises in maternity services. It is important to acknowledge the work of the staff. Every staff member puts his or her best foot forward to provide care and it is important that we acknowledge that. A member of my family worked in Portiuncula a long time ago when the rota was one and two. One worked every day, every second night and every second weekend so I am very much aware of the challenges in maternity services.

I want to talk about maternity services overall. Regarding one frightening figure I found in the past number of months, in February, the caesarean section rate for first-time mothers in Sligo was 73%.

There is a reason that I am raising this issue. When there are smaller units, there are more consultants. However, is there now a challenge in that the skill set is changing because there is not the same number of patients to be cared for? There is a larger number of consultants but they have lower numbers to deal with. Is there now a challenge in relation to the whole skill set situation? How does the HSE propose to deal with that in the smaller units? How many units have under 1,500 deliveries a year? How many consultants are in those units? If there are 1,500 deliveries and five consultants, that is 300 deliveries each. In fairness to the nursing and maternity staff, they are able to deal with a large number of those deliveries without input from the medical consultants. How is it planned to deal with that issue?

Dr. Murphy, as the specialist in that speciality, might address that point. I would underscore the firm answer to the Deputy’s question by saying it is not just the volumetric of birthrate that is associated with maintaining the skill set. There is a fundamental change in the age profile of pregnancy and a whole range of other factors and lifestyle choices in modern-day life that are very different. All of those bring pressure on the availability and maintenance of skill sets. Dr. Murphy will have the main answer.

The Deputy raised important questions on medical education, how people are trained and the changing face of obstetrics. As he correctly said, in the past, people did it one in two or one in three, but that is not really acceptable anymore. All of our units are now intended to have six consultants.

What number of units have under 1,500 deliveries?

We have a large number of units that are under 1,500 deliveries. I am going to explain how things have changed. Many of those will be more hands-on and will be on the labour ward, doing deliveries themselves. We have also seen a change in how we train. Rather than volume as the only metric for training, we now have simulation, and there is a simulation lab in Galway that runs excellent skills and drills. We have prompt drills that occur across the hospital, and Portiuncula would also do them.

That does not deal with the issue I raised, which concerned the Sligo figures for February. There was a caesarean section for 73% of first-time mothers.

The Deputy is talking about a rise in the caesarean section rate in the country. That is correct, and we have identified that over the past number of years. I would never go on one month in any unit because that could represent a small number of first-time mothers. There is a rise in the caesarean section rate in Ireland and the UK. Other countries in Europe have a higher caesarean section rate, and there are variations within those. We do not have the answer as to what to do about that, but there are some reasons for it, such as the age profile of women having babies. The average age of first-time mothers is 33.

There is a challenge in a smaller unit. Trying to maintain the skill set is going to be a challenge now. Previously, in many of the units, it was a one in two rota, a one in three rota or even a one in four rota. It is now probably one in five or one in six. It is a huge change but the volume of people they are dealing with is extremely low.

As was alluded to earlier, the shared posts are important, as is visiting other units and having those up-to-date skills and drills, including in things like caesarean section, managing postpartum haemorrhage and managing obstetric emergencies. These are all very important, and they were not around 15 or 20 years ago.

Senator Rabbitte raised the issue of Professor Morrison not being here. Is there not a whole issue of accountability? A report was produced, the recommendations were set out in it, and then there is the issue of accountability regarding the implementation of those recommendations. It is disappointing that Professor Morrison is not here with regard to why that was not monitored to the extent it should have been, and why we are back here today.

It is important that I take that question. The issue of Professor Morrison’s attendance has been raised several times. I would say to the committee members that I received an invitation from the committee to attend to discuss Portiuncula. I have brought with me the requisite and composite skill sets and level of authority that this subject matter deserves. I have brought the highest level person in the region clinically and managerially, and I have brought the country's leading expert in NWIHP with me. I did not make a choice to not bring Professor Morrison. I did not believe that was necessary.

Is it not about the-----

Hold on, Deputy. In fairness to Professor Morrison, I ask the Deputy to let me answer.

Is there not an issue about accountability?

The Deputy will have to let me answer. I do not want to get into a row with him but he is going to have to let me answer. A person has been named here. He was not invited by me to come. If the Deputy really feels there is a deficit in this committee by his not being here, I will come back another day with him, with no difficulty. I have come here today. In response to Deputy Sherlock, I think I accepted a fair level of responsibility on the part of the HSE for the non-sustainability of the Walker piece. I am quite happy to come back with Professor Morrison if the Deputy really feels that is a deficit.

We still have a problem with accountability. A report was produced a number of years ago, but we are back in a position where a second report has to be undertaken to establish the failings in the system. The report that was produced a number of years ago was to deal with those failings, and it did not. Therefore, the question is about who is in charge and who is accountable. That is the whole issue.

Anybody on this committee, or in the thirty-third and thirty-fourth Dáileanna knows my view on accountability very clearly. I have an absolute focus on learning from error. I absolutely accept responsibility for system or systemic failure.

The reason I am raising this-----

Hold on again, Deputy. I am an absolute believer in and have discharged individual accountability in the health service that has never heretofore been the case. I am not, at this point in time, in possession of any sufficient information that has led me to that third option in respect of individual accountability. I believe there was a fundamental systemic shortcoming on the part of the Irish health service, and in the region, with regard to ensuring that the sustainability of Walker either happened, or if it could not happen, that it was called out earlier. For that, I have accepted responsibility. For that, I have apologised.

I would say to members that as a matter of course, we invite the CEO of the HSE to come, and then it is a matter for the CEO to decide who he brings with him. My experience over the past year is that the CEO has been very willing to come before us and answer our questions, has engaged frankly with the committee and has followed up on our questions. We have had very positive engagements. There is no doubt we will have further engagements on this issue and on maternity services more generally. We will return to this issue in the course of this Oireachtas. I just want to put that on the record. I thank Mr. Gloster for his engagement.

We have 30 minutes left in the committee hearing, if members want to ask additional questions. I call Deputy Daly.

I fully accept Mr. Gloster's bona fides in this matter and accept his explanation. It is his decision to bring his team with him. I accept that without reservation.

I also accept Dr. Murphy's expert evidence on high-risk pregnancies. My point was not directed at Dr. Murphy but concerned the confused information that was being directed out to GPs and the public. I accept her specialty qualifications. I am not an obstetrician. I want to make that clear. I am not questioning Dr. Murphy's expertise.

I want to ask about the evidence on the first seven cases. I am again asking for Dr. Murphy's expert opinion. Does she feel that the risk stratification would have made any difference to the outcome of those seven reviews? Is she party to that type of information?

With regard to the individual cases, the discussions on moving high risk were not directly about a specific case. There were two cases that had gestational diabetes, which is one of the criteria we looked at. Many of them were low-risk cases. If there is a unit that is struggling, where processes were not where we would like to see them, and we know there is a cohort of women who go into pregnancy with a high risk for hypoxic-ischemic encephalopathy, HIE, we potentially should be doing something to try to mitigate that risk in light of the circumstances in Portiuncula.

That was the reasoning, as it were.

I thank Dr. Murphy very much for that. I also recognise some of the changes that have been undertaken in Portiuncula. I am sorry it has taken this to happen, but the ambulatory gynaecology services have been established and there is a huge welcome for that. The direct assessment without having to go to the labour ward is also very welcome. The tender has gone in to improve the communication piece. For the life of me, I cannot understand why it took this to arise for that to happen. That is not just the maternity unit in Portiuncula Hospital; that is the whole hospital. It should have happened before this.

I hope that something as obvious as continued training and professional development would be monitored more closely. Training comes up. It should be a no-brainer. It should be an integral part of professional development.

I take issue with the suggestion that the HIQA audit on 10 and 11 April in 2019 represented a review of the Walker report. It was not. I do not want them to be conflated. I accept that it was a national audit but it is wrong to conflate the audit with a forensic review of the Walker report. I want to put that on the record. I accept that Mr. Gloster has said it; I am not attacking him.

I have very little time and there are two pieces I want to ask about. Is Mr. Gloster happy with the leadership and culture within the unit now that is going to bring us out of this? That is a question that is coming to me from the unit and professionals in it.

I am going to own that because it is ultimately my responsibility. I am happy at the point in time of my decision that the external management team remains in place. The Deputy can take it from that, that there is a way to go before that team can withdraw and we could be fully satisfied with where we are at. That is not a reflection on individual people; that is a reflection on the level of incident that led us to a very difficult decision and therefore the assurance that is required after that. I am happy with the arrangements that are in place today.

I accept that. The last piece is more of a social issue rather than a medical issue. We have some of the highest levels of deprivation in Ballinasloe town and rural deprivation in the east Galway area. I cannot comment on Roscommon and elsewhere. That is measured by Pobal and DEIS.

Yes, that is accepted.

There is significant concern that the very women we would consider to be high risk due to their social status and their risk factors will end up not making it to antenatal care in Galway, and will end up presenting late without any previous care to the maternity unit in Ballinasloe. That is a real and legitimate concern.

On the basis of what the Deputy Daly said, and how he has articulated it, rather than me saying we are doing this, that or the other about it, that is an observation that I had not heard and I want to take it away and seriously consider how I can help the region. It is a very valid point and I was not minded to it.

I appreciate that the clock has gone red but before we finish, whatever deficits occurred in the communication with the most important part of our healthcare system, which is GPs, I take the point with the bona fides with which the Deputy has given it. We will certainly reflect from that and learn from it.

Any points that I have made have not been personal.

That is completely accepted.

I am passionate about the services in my area.

They are all accepted.

I have a few questions to finish up. I might just give them all now and Mr. Gloster can come back. He said a few times that all of this will be evaluated, which is obviously essential. When and how often will the situation be evaluated in terms of knowing that we are going in the right direction? We all need to know that in terms of the recommendations and the implementation of same.

One example given of a risk by Mr. Canavan was in relation to the timing issue and travel. If that comes up in the risk assessment as an issue, which most of us presume it would, how can that be addressed?

My read of the Coulter Smith report is that he was suggesting an external review of the existing 19 maternity units, as opposed to the strategy, which will be coming anyway. He said it is important that someone is identified to take responsibility for the changes and for the continuous monitoring of those changes. As Mr. Gloster said, that has been the failure. Who will that someone be?

There was a suggestion in the same report about an information pack being made available to parents where babies are being transferred and that it should be rolled out nationally. Is it possible that such an information pack could be made available to women who are deemed higher risk and will not be going to Portiuncula? From what I heard from some women who had babies in Portiuncula, they presume that if they are pregnant again, they will not be going there. Could something be done there in terms of an information pack? There are examples about what to include such as directions on parking and all of that.

Of the 12 reviews – some are finished and others are not – a number of them remain under way until next year, is it possible for Mr. Gloster to tell us how many of the 12 cases were out of hours and in how many was the locum consultant called? I know we are not privy to the details of the reviews, nor would I expect to be, but I would appreciate it if he could give us that information.

I will deal with those as quickly as I can. I do not want to use the phrase that the evaluation is "ongoing", because that just frustrates people, but it is. The truth is that the first junction point of evaluation of this particular decision will be nine months after 13 October when we see what the delivery has been like for the women now booked elsewhere.

In relation to travel, if that features as a factor in the lives of people, we would always try to help. Equally, we do not want the ambulance service saturated into one line of call. The region would look at that and do the best it can.

The Deputy referred to the 19 reviews. The Coulter Smith report made the observation that we could just review 19 units in the context of the issues he identified. The Minister has been very clear and I spoke to her as recently as this morning. She is going to take cognisance of all of these issues going into the next maternity strategy. That will of itself comprehend a review of the units against those questions.

As to who is responsible for the changes, it cannot just be one person because my delegated officer is Mr. Canavan, and it has to be at two or three different levels within the system. There are individual people from Mr. Canavan to Dr. Nash out to Professor Morrison and colleagues. That is clearly identifiable to us at least.

The info pack is really interesting. Again, I will take it away. Dr. Murphy might respond to the question. Somebody might also answer the question on whether the incidents occurred out of hours.

With regard to information, that is a very good point. It would solve the issues that have arisen when a baby has to be transferred for cooling elsewhere. Not knowing what was ahead and the hospital they go to was a deficit. We have a national lead for it now for those parents, which will be rolled out across the country. As part of the catastrophic claims report, we will also look at having better communication back from those hospitals with regard to the treatment in the hospital to the referring hospital, let us say, from Crumlin, Temple Street or the Coombe to Portiuncula. A number of initiatives have been identified regarding communication to couples and clinicians, that are ongoing.

I can get the exact number of cases that were out of hours. It is not straightforward because both obstetricians and paediatricians were involved. In a number of cases there were locum paediatricians and obstetricians involved. There are two different types of locum: ones who are there on an ongoing basis, that is, one has been there for more than 12 months, as opposed to weekend locums who just cover for the weekend. There is one case of somebody covering for the weekend.

The witnesses might be able to provide-----

To be fair, the Deputy's question about the 12 cases is very sincere and genuine, what we will be able to do is give the time of delivery being either in the standard day or outside it, on an anonymous basis. I will ask the region to follow that up directly with the Deputy.

I thank Mr. Gloster.

First, I have to say that while this is a really engaging process, I thank Mr. Gloster for being here because, obviously, when he is here he cannot be doing his critical work managing the health services right around the country. A lot of questions have been asked with regard to Portiuncula and how we will get full service resumed again. However, as was mentioned earlier, central to all of this are the poor souls who have been traumatised. I do not know how many they were but I read in the report and it has been mentioned here that three families have taken up the opportunity to engage with the regional clinical director for the women and infants health programme and the regional director for midwifery. There is also a liaison officer constantly there in support. It is traumatic for any woman who has a miscarriage but for anyone who loses a fully mature, soon-to-be-born baby, it is catastrophic for that person and that family. The conversation we are having here is all about making sure that never happens again, or at least that systems are in place to ensure the best possible help and clinical support is given to that person. I do not have a question, per se, but I am conscious that those people are on a very long emotional and traumatic journey through their lives because of what happened and that what we are talking about could have been avoided if systems were in place or functioning better. That is what I get from all of this from beginning to end. We are all on this journey of recovery in many respects. The recovery I am talking about is full service resuming in Portiuncula. I am heartened, when I read and listen to all the commentary all day long from all the contributors, that what the witnesses are about is making sure there is no repeat of what happened and ensuring the best possible practice and all the best and necessary safeguards are put in place for the future service of Portiuncula maternity unit. I asked earlier about when we can anticipate normal service. I take it, when Mr. Gloster said it was impossible to measure but that he would be monitoring that very closely going forward, I have every reason to believe we will have the centre of excellence, please God, in the not-too-distant future, if all the stakeholders play their part.

On the matter of recruitment where people are retiring out, and I have raised this issue before about forward planning, in most of the units, there is a fair idea when people are going to retire out. I know the situation where someone moves from one unit to another cannot be managed, but in a lot of the cases in the HSE, the vacancy is not advertised until the person has actually left work in the unit. What forward planning has now started in the HSE to deal with this issue? Especially in maternity and in the smaller units, there is a need for forward planning, especially where people are due to retire within the following two to three years. Is there a system established so that it is not necessary to rely on locums?

Three things have happened. I took very seriously what the Deputy said the last day. First, all of the regions have now been given an envelope of staffing resource rather than a specific prescription of what it is, and they can utilise that to meet the different pressures and needs they have. Second, there is a clear expectation that we now do anticipatory recruitment. In other words, we do not wait until the day someone retires. The traditional model was that they come back as their own locum while we are then recruiting. We do not wait to do that. The reality is, the projected rate of retirement of consultants, not just in this specialty but generally across the 4,500 consultants, is different in different specialties, and the availability of people to be recruited will become the issue. The timing of anticipating recruitment is being redone. Indeed, partly because of the debate the Deputy had with us at this committee, it certainly-----

This would also apply to nursing staff.

It applies to healthcare workforce recruitment. I made the point on "Six One News" last night that my biggest concern is trying to sustain the rate of recruitment we have done over the last five years in adding 25% to the workforce. However, we need to do better anticipatory recruitment around retirement across all grades. The Deputy is 100% correct on that. That is now-----

The other challenge that is happening, especially with nursing staff, is where they have young families and they are looking to time share. I have come across cases where the HSE management has not been prepared to accommodate them. I refer, in particular, to nursing staff who have young families, where circumstances change and they are no longer able to do the five days a week but they are prepared to do two or three days a week. Have we worked through that as regards individual units? It varies quite a bit in individual hospitals.

I hate saying we are family friendly when there is evidence that are times we are not. Equally, when it comes to the rate or number of people who might apply for a flexible type of working arrangements, to be fair to hospital managers and health service managers, if they do not have some level of control over that, they end up with exactly what the Deputy and I have talked about in this committee for many years, which is an absolute dependence on agency staffing to supplement the lines of the roster. It becomes quite chaotic. However, I absolutely agree with him. To retain staff, we have to go to the greatest level of family friendly that we can.

On the locum issue, it suits some people to stay on as locum. How is that controlled, in the sense that if there is someone in situ, they know very well the HSE is challenged in trying to get a replacement and, therefore, it suits them not to apply for the job but to remain on as locum?

I would be tempted to remove the facility if I thought I could, but the day after I do it I will end up in a specialty where there is no one to provide the service, and I would prefer to have someone providing the service. It is not something I encourage my managers to do-----

However, it is a challenge, especially in the smaller units.

It is an enormous challenge across the health sector at consultant level. It is more of a traditional thing than for the current population of consultants, but it is not something I encourage. I am not a fan of it but sometimes my hands are tied.

I thank Mr. Gloster.

First, I thank the Chair for letting me in. I am not a member of the committee. The witnesses are welcome.

I have a few questions on Portiuncula. There were five cases in 2024. As has been said earlier, we have to be mindful of the parents who have lost children, some of them close to me at home, but it is about resolving a problem and, going forward, making sure it is safe and that we get the services back. Five children were to go to Dublin for therapeutic hypothermia. Is that a high percentage? What is the percentage right around the country? What is the prognosis for those children? Have they met the milestones so far?

Regarding the rate of concern in Portiuncula, they were at 3.82 per 1,000 births against what would be expected on the international standard and the national rate of 1.24 per 1,000 births. Their rates are well outside the range.

I am just asking the question about the other hospitals right around the country. Has an analysis been-----

I am comparing them to those. Portiuncula was at 3.82 and the other hospitals were 1.24 per 1,000 births. Regarding the outcomes, it is a small cohort of children so I do not want to get into identifying them, and I know the Deputy is not asking that. What I can say to him is that some of the outcomes have been catastrophic and some will take time to understand because the nature of the condition is that it can evolve over several years.

Okay. A survey has been done, which I read in the last week, of patient satisfaction in Portiuncula at the moment. In Mr. Gloster's view, has Portiuncula turned a corner? Is it encouraging for the HSE to see? I remember, and the witnesses will remember, a number of years ago, unfortunately, that the hospital in Portlaoise was in difficulty. One of the hospitals the HSE was promoting for certain cases over the last number of months would have been Portlaoise. Obviously, Portlaoise going from where it was to where it is now means the services are there and it is capable of looking after people.

In regard to what was done in Portlaoise, are the witnesses looking to do the same in Portiuncula?

The issues, the time of the issues and what was known about safety indicators were very different in Portlaoise. It now has connections such as the network to the Coombe hospital that I talked about earlier, so its context is very different. To support Portiuncula, we are doing everything that we do for every other site. I absolutely assure the Deputy of that.

One of the recommendations or one of the queries was about theatre and the labour ward. My understanding is that many hospitals around the country are in the same scenario as Portiuncula. Is that correct?

With regard to theatre access?

Theatre and the labour ward are on different levels.

Infrastructure can be challenging in some units. Infrastructure per se was not necessarily the issue. It was a multiplicity of factors in Portiuncula.

I understand that. However, one of the things that was highlighted was the labour area and the theatre were on different levels. That is replicated throughout the country. Why was it picked out there and not everywhere else?

In some of the particulars of the cases there was a delay in moving patients to have an emergency caesarean section. That was one of the issues that was picked up.

Is an overall review of maternity services throughout Ireland going to be undertaken?

Just before the Deputy came in, I was explaining that the maternity strategy concludes in 2026. In the programme for Government, The Minister, Deputy Carroll MacNeill, is going to bring forward a new maternity strategy. To inform that strategy, she will be reviewing all 19 units across a whole range of considerations. I am sorry but I did miss the point of the Deputy's earlier question, and I should have said so. The survey to which he referred of patient experience is different from clinical outcomes.

Yes, I know that.

I was delighted to see the outcome for Portiuncula because I know the quality of what people do there to care is very good.

I wish Mr. Gloster luck in his retirement. He has earned it.

I thank the Deputy.

However, I have one last thing. What is the plan? When talking about the end of 2026, is there a commitment to bring the services that Portiuncula has lost by putting in the resources and getting those services back? What is the plan going forward?

As I have said the plan is, were the conditions in 2025 not there, we would not have made the decision. If those conditions change in the future, we will look at that decision.

I appreciate being here today. I do not attend the health committee regularly but this issue is very close to home. I raised this with Mr. Gloster previously at the Committee of Public Accounts. I appreciate the work that is ongoing to try to improve this situation and ultimately improve outcomes. We have to have positive outcomes. That is what matters most for maternity services at Portiuncula. We are all in agreement on that. As I mentioned at the Committee of Public Accounts, and obviously this is an ongoing and evolving situation, there is a significant hinterland and significant area in which people now have to travel a much further distance to get the maternity services required. How was the external management committee appointed? How did that process unfold? Subsequent to that, is it that external management committee or review team that is subsequently charged with the implementation of same, obviously in conjunction with hospital management and professionals who are trying to do their jobs? How does that work? How do we get to a better position where it becomes more reassuring both to mothers and to everyone in the community?

The external management team has two functions. I agreed to its appointment early in 2025 after the chief clinical officer of the HSE and the clinical director of National Women and Infants Health Programme, NWIHP, Dr. Murphy, advised me that this was the appropriate step to take. At that point, Dr. Pat Nash and Mr. Tony Canavan put the team together. Thankfully, three people took up that challenge. We did not expect them to be there so long, but we felt it was necessary. That is the first point.

They have a significant role in the assurance of the unit operating there today and the women who will continue to be booked there, whereas the movement of the higher risk pregnancies is a much wider regional implementation team which Dr. Nash and Mr. Canavan are leading. However, the external management team feeds into everything we do but is more focused on what is going on in Portiuncula than the people who have now moved.

Clearly, the focus right now is on making sure that the pregnancies being dealt with at Portiuncula are dealt with to the highest standards of care.

That is correct.

Is there any focus on improving the situation to a point that high risk pregnancies can return to Portiuncula?

There is an absolute focus on bringing Portiuncula to the best level that it can be brought to, including reducing dependence on locums and increasing the capability of the availability of specialists who operate in Portiuncula. That will be one part of perhaps reducing the risk and trends we have seen. That would be a big part of a decision to be made in the future. Yes, there is a continued focus. We cannot continue to operate Portiuncula in the way it had got to, even for the pregnancies we are keeping. We have to and we are improving it.

When Mr. Gloster says that - the place it had got to, are we in a much better place than that now?

I am more assured about where we have got to today because of the external management team and because of the openness of the outcomes of the cumulative incidents. I am more assured from what NWIHP tells me about how the unit is currently working and I am more assured because of the particular decision that was made about the higher risk pregnancies.

Roughly how many pregnancies were being dealt with at Portiuncula per annum before this decision was taken?

In 2024, there were just under 1,300 deliveries in Portiuncula.

Roughly, what percentage of that would be considered high risk and has now been diverted elsewhere?

Based on the high risk criteria, we are expecting the care of between 250 and 300 women to be transferred.

About 20%. It would be remiss of me to look at Portiuncula in isolation, so are there concerns about the ability of Galway University Hospitals, GUH, to handle the extra load coming its way?

Part of the risk assessment of the transfer was the safety risk that GUH could manage that increased volume of women as well as the risk of deskilling the staff in Portiuncula. A risk assessment has been done. GUH has that capacity available. We made additional theatre capacity available in GUH for higher risk women to ensure there is sufficient theatre capacity. In the other aspects of care, antenatal and postnatal care, there is sufficient capacity. We have recruited additional staff to support that.

To summarise, what we are hearing this morning is that there are very real concerns from the HSE around the risks and the adverse outcomes among people with high-risk pregnancies. That is the reason services had to be moved. There are ongoing issues around governance, staffing, recruitment and some of the infrastructure in the hospital. The external management team remains in place. Matters are ongoing but there is a long-term commitment to the unit and to developing the services. We will probably engage again on this, if that is a fair enough summary of where we are at.

It will inevitably require further engagement. As the maternity strategy progresses with the Minister, it will contextualise Portiuncula in the rest of the 19 units. I can only say to the people of Ballinasloe and the people who use Portiuncula that I wish it were different. I am sorry it is not. However, I am absolutely clear that for the women who are booked to go there and continue to be booked to go there, I am very happy to recommend that they continue to go there. We are absolutely committed to the healthcare system in Portiuncula hospital.

I thank the witnesses for their time this morning and for their ongoing engagement on these issues. That concludes this meeting. I thank the HSE for its engagement on the matter. As I have said, given the context and the concerns regarding maternity services at Portiuncula hospital, we will keep this matter under consideration. We will also consider the new national strategy. The joint committee is adjourned until 3.30 p.m. on Tuesday, 13 January 2026, when we will meet in private session. I wish members a happy Christmas.