David Cullinane (Waterford, Sinn Fein)
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I move:

That Dáil Éireann: condemns the abandonment of patients in Clare, Limerick, and Tipperary following the wholesale cancellation of scheduled and planned care for several weeks at University Hospital Limerick (UHL) in August 2024;

notes the forthcoming publication of the report of the independent investigation by retired Chief Justice, Mr Justice Frank Clarke, into the care of Ms Aoife Johnston and her tragic, premature passing in 2022;

acknowledges that a review of emergency and urgent care services in the Mid-West Region is underway;

recalls that:

- the requisite capacity to replace emergency departments (EDs) at Ennis and Nenagh was never delivered at UHL, and that the closure of those EDs left UHL as a single point of failure with no backup in the region;

- the closure of the Ennis and Nenagh EDs was done without the agreement of local general practitioners (GPs), who were expected to deliver urgent care in the absence of the EDs;

- commitments given by successive governments to create a centre of excellence in emergency care at UHL have never been followed through; and

- UHL ED has invariably been described by clinicians, patients, families, and advocates as "unsafe", "akin to a warzone", "overcrowded", and "a crisis situation";

further notes that:

- hospital bed capacity is low in the Mid-West, at an estimated two acute inpatient beds per 1,000 population in comparison to a statewide average of 2.2, a 9 per cent shortfall compared to other regions;

- only 118 additional beds have been delivered at UHL since 2020, despite a need for at least 250 beds to close the known deficit which has existed since the closure of emergency departments in Ennis and Nenagh a decade-and-a-half ago;

- inpatient waiting lists in the Mid-West have risen from 4,951 to 5,348 from August 2023 to August 2024, and the percentage of patients waiting longer than the Sláintecare target wait time has risen from 64 per cent to 69 per cent, with 78 per cent of children over the target wait;

- more than 21,000 patients were admitted to UHL without a proper bed across 2023, making UHL the most overcrowded hospital in the State and 70 per cent worse than the second-place hospital, according to the Irish Nurses and Midwives Organisation; and

- there are five EDs in the Health Service Executive (HSE) Dublin and South-East Region, which serves a population of circa 970,000, in comparison to just one ED in the HSE Mid-West Region, which serves a population of circa 410,000 people;

resolves that additional bed capacity for UHL must be fast tracked and that additional emergency and urgent care capacity is needed across the region; and

calls on the Government to:

- ensure that acute healthcare delivery in the Mid-West Region is safe, population based, and clinically underpinned;

- commit to a second Model 3 hospital, with an ED, for the Mid-West Region;

- fast track additional bed capacity for UHL to urgently bring the region's acute bed capacity in line with other regions;

- develop protected inpatient elective capacity for the Mid-West Region, to separate scheduled and unscheduled care;

- develop a new model of urgent and out-of-hours care, including a public GP contract, enhanced pharmacy services, and 24/7 urgent care at Ennis, Nenagh, and St John's hospitals;

- invest in home support and local community healthcare services, to improve discharge rates and reduce pressure on UHL;

- fund the National Ambulance Service workforce plan, to support rapid access to emergency care; and

- legislate to mandate safe staffing levels in every hospital, and expedite the Patient Safety (Licensing) Bill.

Given that this is our first opportunity to comment on Mr. Justice Clarke's report into the death of Aoife Johnston, I pass on my sympathies to her parents, family and all of her friends. I am sure the Minister will agree that the report is devastating. The key finding - that Aoife Johnston's death was almost certainly avoidable - is heartbreaking for her family. Anything we do to improve healthcare in the mid-west region must be done with Aoife in mind, but many other families have suffered because of unsafe care and a lack of capacity at University Hospital Limerick, UHL.

For a long time we have been talking about a lack of healthcare capacity in the mid-west. The report from Mr. Justice Clarke, as devastating as it is for Aoife's family, points out very clearly that the decision made all those years ago to close emergency departments in Ennis, Nenagh and St. John's has had dire consequences for health services in the mid-west region because the capacity was simply not put into Limerick. The report points to the promise made at the time to the effect that "we will remove the services in the other areas but we will build a centre of excellence in Limerick" and that health outcomes and healthcare capacity and access would be better for patients. I do not believe the Minister or anybody else can say that has worked out or that the people of the mid-west have got the safe healthcare services they need and deserve.

I attended a meeting of the Oireachtas health committee in Limerick earlier this year. The meeting was also attended by senior management of UHL, clinicians, the head of the HSE and representatives from the healthcare trade unions, whom we met separately as well. The head of the HSE and hospital management conceded that on an almost daily basis, patients present to the emergency department in Limerick who are in a need of beds but the beds are not there. They also acknowledged, as we know from experience, that far too many people are left in the emergency department without getting the care they need.

The work environment in the hospital is highly pressurised for staff. It is very unfair to ask nurses, doctors, healthcare assistants and nurses to work in a highly dangerous and pressurised work environment where decisions have to be made to save people's lives and where staff are doing their best but in the most difficult, highly charged and pressurised situations. It is an impossible task that we have set for those healthcare professionals.

We owe it to the people who live in the mid-west to provide safe healthcare services. I have always said in this House - and will repeat it to the Minister in the context of this debate - that I believe every region deserves safe healthcare services. Every region should have healthcare services based on health needs but also on population. Those services have to be clinically underpinned. The health services we provide must meet all of those criteria.

I live in the south east. There are three model 3 hospitals and three emergency departments in the south east. We have Wexford General Hospital, St. Luke's Hospital in Kilkenny and University Hospital Waterford. In the mid-west, there is one emergency department, one model 4 hospital - University Hospital Limerick - but no model 3 hospital. That is quite unusual in a regional context. There is a reasonable demand from the people who live in the region for that to be corrected. A HIQA review is examining the position, but there is a compelling case to be made for a second emergency department and a second model 3 hospital in the region.

People such as my colleague Deputy Quinlivan, Joanne Collins, the Sinn Féin representative for County Limerick, who is in the Public Gallery and many more such as those in campaign groups and individuals who have protesting outside the hospital and elsewhere for almost a decade have been looking for additional capacity in UHL and in the other hospitals as well. Some progress has been made, but nowhere near enough.

Deputy Quinlivan and I published a plan a number of months ago in which we set out, from our perspective, what is needed. We need additional beds to get ahead of the problem, we need 24-hour urgent care in all of the hospitals in the region, we need to beef up community and primary care, because these are part of the problem as well, and we need to better organise the emergency department to ensure that patients are prioritised better. That is one of the recommendations in Mr. Justice Clarke's report as well. All of that capacity has to be put in place, but we also need to look at the other hospitals in the region and decide what is the best and most optimum care we can provide for the people in the mid-west region. I appeal to the Minister to work with all of us in that vein, particularly as I want to make sure that the people in mid-west have the safe and accessible healthcare services they deserve.

Martin Browne (Tipperary, Sinn Fein)
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I commend Deputy Cullinane for bringing the Private Members' motion before the House. Before I begin, I want to take a moment to express my sincere condolences to the family, friends and loved ones of Aoife Johnson. The conditions that Aoife encountered when she arrived at the emergency department of University Hospital Limerick should never have been present. Indeed, the conditions that the people of the mid-west have been forced to deal with since the reconfiguration of services should never have been allowed to develop, but they were.

Ahead of the removal of the emergency department at Nenagh Hospital, Ennis Hospital and St. John's Hospital, the Horwath report emphasised that a relocation of UHL and the closing of other departments should not take place until the capacity of UHL was increased. That capacity was never delivered and, as a consequence, UHL has been left as a single point of failure with no back-up in the region. Most recently, the Clarke report reminded us of that by saying: “the fact remains that, even today, some fifteen years later, the capacity of Dooradoyle is significantly below that recommended by the Horwath Report as a pre-condition to closing the other emergency departments in the Midwest Region”.

Even those estimates of the increases that are needed to facilitate concentration in Dooradoyle are likely to be out of date. Instead, hospital bed capacity in the Mid-west is at a ratio that is a 9% shortfall compared with other regions. While there are five emergency departments in the HSE Dublin and south-east regions per population of approximately 970,000 people, the mid-west has only one for a population of 413,000. I also note that patient and client care staffing numbers across the UHL group have all reduced in numbers in the lifetime of this Government. It is hardly right, is it, considering?

Effectively, the mid-west has been disregarded like no other region under successive health Ministers. Given the failure to deliver on this, a HIQA review of emergency care must be tasked with examining a suitable location for the scaling up of services to provide a partner for UHL. The case for a second model 3 hospital with an emergency department for the mid-west region must be pursued, but in the meantime, the issue at hand must be addressed. That is why Sinn Féin would fast track additional bed capacity for UHL to urgently bring the region’s acute bed capacity in line with other regions. We are calling on this Government to do the same.

We are aware of the consequences of this lack of capacity. Some 21,000 patients were admitted to UHL without a proper bed in 2023 alone, leaving scenes that are invariably described by clinicians, patients and families alike as akin to a war zone. Management and staff are working under intolerable conditions. We are calling on the Government to legislate to mandate safe staffing levels in every hospital and expedite the patient safety Bill. Additionally, where is the responsibility? Will the Minister take responsibility for unclear protocols in place to deal with ongoing overcrowding which lead to patients being placed on the wrong pathway to care? Will the Minister admit that the approach that has been followed to date has been wrong, that it has not addressed the huge pressure that the hospital has been under, and the consequent failings at a high level of administration to ensure the emergency department can cope?

We need a thought-out, clinically underpinned and urgent response to what is going on here. Our plan involves the development of protected inpatient elective capacity for the mid-west region and separating scheduled and unscheduled care. What we do not need is a response to each crisis that heaps further burdens on the people of the mid-west. How many people in north Tipperary are being asked to give up places for elderly people at the Nenagh community nursing unit, which is being farmed out to the private sector as a step-down facility? What we do not need is the continuing crisis response that most recently led to the cancellation of elective procedures during the month of August. Again, this negatively impacts the health and wellbeing of people in the mid-west by limiting their abilities to get the healthcare they need. That is why we will also develop a new model of urgent and out-of-care enhanced pharmacy services and 24-7 urgent care at Ennis Hospital, Nenagh Hospital and St. John’s Hospital. The latter has been alluded to by this Government, but again, the people of the mid-west are being left in limbo with no firm indication that this will be provided. The people of the region also need the security to know that this location will not hinder an emergency. That is why we are highlighting the need to fund the National Ambulance Service workforce plan in order to support rapid access to emergency care. Additional bed capacity for UHL must be fast-tracked. Additional emergency and urgent care capacity is needed across the region. The mid-west deserves safe healthcare services and we have a plan to deliver capacity to UHL and invest in emergency and urgent care across the mid-west.

Stephen Donnelly (Wicklow, Fianna Fail)
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I thank the Deputies opposite for tabling tonight's motion. It provides a welcome and much-needed opportunity to discuss the additional capacity and reforms that are needed in the mid-west region to provide people with something they do not currently have and that they must have, which is a well-functioning emergency department and timely access to emergency and urgent care.

It is every parent's worst nightmare to lose a child. That nightmare was compounded for Carol and James, parents to Aoife Johnston, who watched their daughter deteriorate at UHL before she succumbed to sepsis. As former Chief Justice Frank Clarke said in his report: "To lose a child in the fraught and traumatic circumstances of Aoife's death is beyond understanding. To be present and feel powerless is unimaginable." Aoife was left without appropriate treatment for more than 13 hours. Aoife faced delays at so many different stages during her time in the hospital, from admission, to triage and assessment, to diagnosis. Eventually, she received treatment that should have been administered many hours previously. As we all know, and as Deputies opposite stated, had Aoife been seen and treated in a timely manner, it is very likely that she would be alive today.

The report by former Chief Justice Frank Clarke highlights a number of factors that contributed to delayed treatment and Aoife's death. It also contains a number of recommendations. The HSE's chief clinical officer, Dr. Colm Henry, is setting up a structure to oversee the immediate implementation of all of the recommendations of the Clarke report, which I accept in full.

Mr. Justice Clarke commented on bed capacity in his report. That goes to the core of what we are debating here this evening. I have said before that there is no doubt the mid-west has had too few hospital beds for too many years. This Government is responding to that with an unprecedented level of investment in new beds. So far, we have added 160 extra hospital beds to the hospital group, including ten new critical-care beds. These ten critical-care beds, along with 108 new beds, have already been delivered and added to UHL but, critically, far more beds are on the way.

Projects that are currently live and under construction at UHL will add another 208 hospital beds. These are: a new 16-bed unit, which will be opened by the end of this year; a new 96-bed block to be delivered in the first quarter of next year and; a second new 96-bed block to open in 2028. Enabling works have already commenced on this second block. In addition to all of this, as part of the new national beds plan launched earlier this year, I committed to another 84 new beds for UHL.

Deputy Quinlivan referenced a report which stated that UHL needs an extra 250 beds. We are adding 410, so we are going miles beyond the recommendation to add 250 beds. To put that into context, the 410 beds we are adding at UHL is the equivalent in beds of a model 4 hospital. In fact, what we are doing is doubling the beds at UHL.

As well as the investment in UHL, we have been and are continuing to invest in more beds right across the region. We are doubling the bed capacity at Ennis Hospital. We are increasing the bed capacity at Nenagh Hospital by more than a half. We are increasing the beds at St. John's Hospital by more than three quarters and we are more than doubling the beds at Croom Hospital.

How does this all add up for the region? When this Government was elected in 2020, there were just under 700 hospital beds in the mid-west. We are adding an extra 542 beds. That is an 80% increase in the number of hospital beds in the mid-west. It is the equivalent in bed numbers to a full model 4 hospital, plus a full new model 3 hospital. A total of 160 of these beds have already been delivered, while more than 200 more are under construction. They will open later this year, and through next year and beyond. The remainder have all been identified at a detailed level for each of the hospitals. Planning is now under way on that.

It is the biggest investment in hospital capacity in the mid-west in decades, possibly ever, but I am not sure. Deputies referenced a Deloitte report from two years ago that was commissioned by the University Limerick Hospitals Group. We are going well beyond the recommendation for the region in the Deloitte report. Why are we doing it? Because it was badly needed. We are very proud to be delivering it. In 2020, when this Government came into office, the mid-west had the lowest level of hospital beds per population of any of the six regions. Between the beds that we are adding and the ones we have already added, the mid-west will end up with the second highest level of beds per capita of the six regions. We are not stopping there. A site has been identified for the Limerick surgical hub at Scoil Carmel. When it is fully operational, every year it will be able to provide an extra 4,000 extra day-case procedures, 6,000 extra minor operations, and more than 18,000 extra outpatient consultations.

As Deputies are aware, we are investing in the workforce to support all of this. In fact, in UHL alone, the workforce has risen by more than 1,100 in the term of this Government. That is a 40% increase in staff in four years. Those staff are doing a very good job. I too commend them for what they are doing. While we are all focused on overcrowding, it is worth pointing out that - thanks to the efforts of local healthcare staff - the waiting lists for outpatients have been falling dramatically in recent years at UHL. In addition to all of this capacity, I have asked our healthcare regulator, HIQA, to consider the case for a second emergency department within the region.

There has been a big increase in community care investment as well, be it primary care teams, older persons' teams, ambulance services and primary care centres, but I will focus this evening on hospital care given that it is the broad thrust of the debate. We have all discussed this matter before and I think we are in agreement on it. While more capacity is essential, it is only half of what is required to deliver the health service the people in the mid-west need and deserve. The other half of the answer is fundamental reform, particularly in UHL. In his report, Mr. Justice Clarke highlights unclear protocols, ad hoc systems, poor internal communication and a failure to deploy the escalation protocol.

The HSE published another report into UHL last week. The report was compiled by Ms Grace Rothwell, who led the turnaround at University Hospital Waterford, Dr. Fergal Hickey, retired emergency medicine consultant, and Ms Orla Kavanagh, director of nursing in Waterford. That report too made very stark observations about work practices at UHL. They reported that they saw limited senior clinicians and management in the inpatient clinical areas. They concluded that "greater presence and input from senior nursing management and the senior medical workforce [consultants] is required to enable more timely responsiveness to patient flow needs." They reported that it was unclear at times who was in charge.

The healthcare regulator, HIQA, has also pointed out that work practice reforms are needed. In its last report into UHL, HIQA noted that progress was being made on a number of fronts, but that the progress was relatively new and not yet at scale. Some steps have been taken. I acknowledge that good work is going on in UHL to bring in these reforms, but greater progress is needed. We know the reforms work. We have seen them work in Deputy Cullinane's local hospital in Waterford, and in Tullamore. We also know the combination of extra capacity and reform works. The reason UHL's emergency department got much worse this year when nearly every other hospital in the country was getting better, is that it was one hospital where the reforms had not been brought in at the level we are seeing in many other hospitals. However, I still fully accept the need for significant additional capacity, which is happening.

This Government recognises the challenges in health services in the mid-west region. I recognise the challenges for people in the mid-west. I hear the concerns they have about going to their own hospital. Nobody should be concerned about going to their own hospital to receive emergency care.

I recognise the distress this causes patients. I have met many patients and have spoken to their families. It causes undue stress and hardship for our healthcare professionals, many of whom I have discussed this with.

I again thank the Deputies for tabling the motion. I agree with a lot of what I heard from Deputy Cullinane in terms of the need for a lot more capacity. I hope he and Sinn Féin join me in stating that while capacity is needed, we must have fundamental reforms, the likes of which we are seeing in other hospitals around the country. We know they work and we have to see them in UHL as well.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Deputy O'Rourke is sharing time with Deputies O'Reilly and Conway-Walsh.

Darren O'Rourke (Meath East, Sinn Fein)
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I thank Deputy Cullinane for bringing forward this important motion. I extend my deepest sympathies to the family, friends and loved ones of Aoife Johnston.

In my contribution, I want to focus on capacity and call out what has been a dominant theme in healthcare planning in this jurisdiction and State for the past 30 years, namely, centralisation. We had the Hanly report at the start of the decade, and then the Teamwork report. Such reports always point towards centralisation. I remember at the time those reports were published, they felt like a foregone conclusion in that they pointed towards centres of excellence. Of course, the experience of communities was something very different. It was one of closure, centralisation and a lack of capacity and follow-through in terms of the delivery of supports, services and capacity. We never saw centres of excellence. I acknowledge that significant progress was made on the cancer programme, but that one-size-fits-all approach did not fit all. The mid-west region is the exemplar of that failed policy.

There were proposals to close emergency departments in Ennis, Mallow, St. John's, Dundalk, Nenagh, Roscommon, Navan and elsewhere. Practically all of those departments, with the exception of Navan, were closed. In many ways, they were closed by stealth via reduced funding for services. It was claimed that they were unsafe and publicly announced as being unsafe, and closed. In many cases, what replaced them was equally unsafe or worse. The truth is that the mid-west could be any region had that policy been implemented in the same way elsewhere.

I represent the county of Meath. The Minister is familiar with the case we have made for many a year regarding Navan hospital. It is still referenced in stated policy in the small hospital framework. We have heard from consultants in Navan and Our Lady of Lourdes Hospital. We want the future of Navan emergency department to be secured. I welcome the reprieve that it has had under the Minister's watch, but we need more. We need a similar investment plan for the emergency department and ICU in Navan hospital to ensure it has a sustainable future and can serve the growing population in County Meath and the wider area. As long as we have the stated policy in the small hospital framework that Navan hospital's emergency department is to follow the likes of Roscommon, Nenagh and Ennis, it does not have a sustainable future. I call on the Minister to ensure the policy is changed and the people of the north east have the same safe staffing levels as the people of the mid-west.

Louise O'Reilly (Dublin Fingal, Sinn Fein)
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I want to start by offering my condolences to the family, friends and loved ones of Aoife Johnston. I have read sections of the report and your heart would break in half listening to what happened to her parents. It must have been awful. As the report said, the family felt powerless amid all of the chaos of accident and emergency all around them. My grandmother died in accident and emergency and it is not an appropriate place to grieve the loss of a loved one. My grandmother had lived a very good life and had her family. Aoife Johnston's life was only starting. The grief her parents, friends and family must feel is, quite frankly, unimaginable. The hope is that some good may come and some lessons might be learned, but this is crisis is not something that has emerged in recent times.

Before I came in here, I was looking back over coverage of previous times. Back in 2009, when Ennis, Nenagh and St. John's emergency departments were closed, I was the national nursing officer for SIPTU, along with Mary Fogarty, who was and still is the INMO representative for what was the Midwest Regional Hospital, now UHL. We lobbied Ministers very heavily, among them James Reilly. There is turn and turn about; it is Fine Gael's turn one day and Fianna Fáil's the next. They support each other. We lobbied James Reilly in the first instance.

We thought that conditions were intolerable. I spoke to members I represented at the time and they described the conditions as being like a war zone. In the intervening time, it has only gotten worse. I want to use some of my time to talk about the people who are working in those conditions and are, in effect, along with the patients, at the business end of the policies and failures of successive governments. When hospitals and accident and emergency departments are overcrowded, patients suffer and die and staff are assaulted. We know this. The conditions that staff are working under are unimaginable.

Every promise that has been made from James Reilly to the Taoiseach, Deputy Harris, and the current Minister, has been broken. I am sure the Minister will forgive people if they take with a pinch of salt any promises he might make here today. I urge the Minister to not just accept the motion or simply nod it through. I urge him to act on what is in it . If he is not prepared or able to do that, I respectfully suggest that he make way for a Minister and Government that will.

Rose Conway-Walsh (Mayo, Sinn Fein)
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At the outset, I want to send my condolences to the family of Aoife Johnston, a beautiful 16-year-old girl who lost her life. It could have been completely avoidable. That is the issue in terms of the healthcare we are delivering in 2024. How many more people have had their lives cut short because they have not received the timely healthcare they need and deserve? We do not know exactly how many have been affected, but many families know that their loved ones would have lived longer or be here today if they had received the right care on time.

Patient safety has to be the heart of what we do. The truth is that many people today, including members of my family, are free to access hospitals. How have we arrived at a situation whereby people, instead of trusting in a health system, are afraid to access the healthcare they need? We have to deliver safe health in hospitals in the mid-west, as well as in the rest of the country. This should never have happened.

The Minister spoke about reform. The Taoiseach was in the health portfolio and did not deliver reform, nor did any other Fine Gael or Fianna Fáil Minister over the years. Instead, we have had report after report from private consultants telling us what should be done instead of getting down on the floor and talking to the staff who are trying to deliver services on a daily basis.

While I am talking about health, I have to talk to the Minister about the constituent I wrote to him and the Taoiseach about. A young man has scoliosis and has been left to wait. His family are now distressed that he has received a diagnosis that he is now not fit for surgical intervention. I received a response from the Taoiseach, who was Minister for Health, who said, "I wish – and names the child – and his family all the best".

He has been failed by the health system despite being promised - promised - in 2017 that those with scoliosis would be treated. I had to look at that child when he was wheeled into my office a couple of weeks ago, which prompted me to write to the Government. One member of the Government is passing to another. The Taoiseach is passing to the Minister for Health who is passing to the HSE and it is no one's fault that we have ended up in a situation where such people's lives are being cut short. And the Taoiseach wishes them all the best. I will leave it at that.

Alan Kelly (Tipperary, Labour)
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I thank Sinn Féin for tabling the motion. It is a pertinent motion because my father is in an ambulance on the way to UHL at the moment. I have just come off the phone. That is why I have been in and out a bit. He has been quite unwell lately. Both of my parents have been quite unwell for some time and the last thing my father ever wants to do is to go to UHL. Forget about politics for a minute; this is my father. The last thing that man wants to do is to go in to UHL. That is a terrible indictment of all of us.

I was told previously that anyone over 80 would be prioritised. That went out the window, as we know. He is dreading what he is facing into. I have been there loads of times previously when he was on trolleys for days. A young man from Limerick in his forties who was sick offered to swap his bed for my father's trolley the last time he was in UHL, but it was not allowed. I do not know what I am facing into in the next hours, days and weeks, but it is an indictment that a man who worked hard all his life is crying and absolutely dreading going in there. People from where I live - I live very close to Limerick hospital, closer than some of the other TDs in the mid-west, although I live in Tipperary - do not want to go into UHL because of the situation we have been left with. It is an indictment of us all that people who are 85 years of age have to worry so much, not just about what is wrong with them, but also about the service provision and how it could affect them. They wonder whether it is worse to go in. Anyone of a certain age in the mid-west would say the same thing my father says to me. They just do not want to go in there. Many times I have heard people say they would rather stay at home and face the consequences. What in the name of God is going on when that is the scenario?

I have spoken more about this topic than I have about any other topic in my political career. It is the reason I got involved in politics. In my office, I have a placard from the mid-noughties. It is a note to Hanly. Then there was the Teamwork report and everything else.

I do not want to repeat all the stuff I have said here. I do not have the time. What happened to Aoife Johnston was an absolute disgrace and there are more than her. It is a failure of the system, but one that, dare I say it, was predictable. We do not know what has happened down through the years. The simple facts of the matter are - I am not just talking about the accident and emergency department - that the decision to centralise everything in UHL was utter madness because it was not followed through with resources. The country was going down the tubes at the time so it was never going to happen and the people of the mid-west have been the guinea pigs for reconfiguration. We have suffered.

The community services cannot deal with it because the acute system is so bad. We simply do not have the community facilities because the acute system cannot and will not be able to deal with it. Various people have been in charge of the acute and non-acute systems across the mid-west for the 20 years I have been in politics. In those past 20 years, I do not care who was in charge. I am not sure how anyone could ever manage it, it is that bad.

Some really good things happen outside it. The best cancer service in Ireland was developed in Limerick. I know all about it. However, in recent months that has been suffering. This is one point I have not raised before. Will the Minister look into this because I know a lot of people who are very worried about it. There were never waiting times for chemotherapy in Limerick. It was very efficient. I have heard more people compliment it than I have eaten dinners. It is an amazing service run by amazing people, but the lack of specialised nurses there at the moment means there is now a prioritisation list. Basically, it depends on how advanced a person's cancer is and all the other metrics. That is deeply worrying. Will the Minister please ask how we can get the required specialist nurses into that system again to ensure it does not happen? Those people certainly, of all the people who go in, outside trauma, are the people we need to prioritise. They are now suffering. It has become so bad that scalp cooling has now ceased because they do not have the capacity to do it any more. For patients with cancer, scalp cooling is important. It is a real issue. I say this and ask that we park the politics for a second. As bad as the situation is in UHL, getting in through the system, the cancer service is there. Until a year ago, key performance indicators, KPIs, were the top in Ireland. They have now dropped and that is down to resources.

I acknowledge the former clinical lead, Dr. Gerry Burke who for many years fought with the system, to his own detriment, may I add. He pointed out the resource deficiencies in the mid-west. I accept that progress has been made. It was badly needed. It is as obvious as the eyes in our heads.

I did not come into the Chamber to say this. In his speech the Minister said the 96-bed block would be open in the first quarter of next year. Last weekend the chief executive of the HSE said it will be mid-year next year.

Stephen Donnelly (Wicklow, Fianna Fail)
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I said end of Quarter 1.

Alan Kelly (Tipperary, Labour)
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No, you did not. I listened back.

Stephen Donnelly (Wicklow, Fianna Fail)
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I will check.

Alan Kelly (Tipperary, Labour)
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He said it will be mid year. Why do I always watch that? It is not only because we need it. It is because the opening of our famous nursing home in Nenagh is dependent on it. When that block opens, our nursing home will return to being a nursing home. It should never have happened.

Medical assessment units, MAUs, were meant to be open 24 hours. That will not happen. I think the Minister has acknowledged it will not or else Mr. Gloster has. That is not the issue. Then that changed to them being open until midnight. That will not happen either. I just spoke to the nurses in Nenagh. There is not a hope in hell. They do not have the capacity. They do not have the consultants, the diagnostics, the bloods or in any way, shape or form, the means to do that. I would love if they were open. I am a massive fan of the MAUs. They prevent people ending up in hospital. The other issue is that, due to the lack of beds, the fact that we have a 50-bed nursing home sitting beside the hospital that now has 18 or 20 people in it, has not made any difference to the actual number of people on trolleys and overcrowding. The people in the hospital cannot go anywhere. They cannot get into a nursing home. I spend hours - hours - every week trying to get people into nursing homes. I ring as far away as Birr, Portlaoise and everywhere because our nursing homes are full. People have to wait for someone to pass away, while we have a nursing home that is not being used. It is counterproductive because the people who need to go into it are staying in hospital.

I put in a parliamentary question some time ago about the length of hospital stays. I asked about patients who are in for more than six months, nine months and a year. The number of people who spend more than six months in a hospital because they have nowhere else to go is absolutely startling. We need to deal with that. They cannot go anywhere because some of them are of such high dependency that no private nursing home will take them. That is how stark the situation is. They are taking up beds at €1,600 a night. Even if we look at the situation from a financial point of view, it is madness, let alone that we need to be considerate of these people in providing care for them.

Will the Minister please deal with the issues I have outlined in regard to cancer care in Limerick? The situation I described is from the horse's mouth. I ask that he readjust in respect of the MAUs. I respect what is happening on the capital side but the dates indicated will not be met. I hope the delivery will happen as quickly as possible. Most of all, when it comes to the pathways for patients in the community and in acute care, including my poor dad, who is on his way to hospital right now, there must be positive change in the medium term. We will not have all these issues solved in the next year or two. We need interim steps and pathways to manage the situation while we have these capacity issues.

Róisín Shortall (Dublin North West, Social Democrats)
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I very much welcome this timely motion on healthcare capacity in the mid-west. I thank Sinn Féin for tabling it.

Following publication of the Clarke report into Aoife Johnston's tragic death, there must be accountability at both political and management level. Notwithstanding its shortcomings, the report effectively highlights the underlying causes of compromised patient care and safety at UHL, which led to Aoife Johnston's "almost certainly avoidable" death, as the report said. They include failures in systems, missing pathways of care and persistent overcrowding. The report found that systems and care pathways were either deficient or completely absent. That is a clear failure of hospital management. The accompanying support team report noted that it is "unclear... who is in charge on the UHL site on any given day". This is a shocking assessment. I appreciate that disciplinary proceedings are under way and that management structures are set to change under the new regions, but we must ensure that accountability is more than just a buzzword. There must be consequences for the negligence that contributed to Aoife's tragic death.

Political accountability is also required. The chronic overcrowding and lack of capacity in UHL is a result of political decisions. That must be reckoned with. There has been a persistent and outrageous denial of the failure to adequately resource the original reconfiguration in the mid-west. The accountability for those decisions rests with a number of Ministers for Health right up to the present day. As it stands, University Limerick Hospitals Group is the only hospital group in the country without a level 3 hospital. Five other hospital groups have at least three model 3 hospitals and some even have multiple model 4 hospitals. University Limerick Hospitals Group has only one level 3 facility. It is a complete outlier in having only one emergency department. All the other hospital groups have multiple emergency departments.

It is more than two years since HIQA stated that the absence of a model 3 hospital in the region significantly impacted the effective working of UHL's emergency department. I do not know why the Minister has to look for a second report from HIQA. The authority has been very clear on what the problem is in the region. The question must be asked as to why has it taken the current Minister for Health until this year, 15 years after reconfiguration, to examine again whether a level 3 hospital is required in the mid-west. The 2008 Horwath review of acute hospital services in the mid-west made clear that the closure of other emergency departments should not occur without increased capacity in Dooradoyle. The report recommended a capacity of 642 inpatient beds in UHL as a precondition to closing the other emergency departments. This was ignored and the three smaller emergency departments in Ennis, Nenagh and St. John's hospitals were closed. At the time, UHL had only 375 inpatient beds. While that figure has substantially increased to 535, it is still well below the 642 recommended back in 2008. We see how much the population of the region has increased since then. According to this Government's own inpatient bed capacity expansion plan, last December, the mid-west region still had the lowest ratio of inpatient beds, with two beds per 1,000 people.

Questions also remain about the scarcity of consultants in University Limerick Hospitals Group. The Minister has pointed to the low number of consultants who have taken the new public-only contract, which means they are still working only a five-day week and there are problems with cover and decision-making at the weekends. That is a valid point. However, the fact remains there are far fewer consultants in University Limerick Hospitals Group than there are in other emergency departments. When I raised this with the Minister in May, he was unable to explain how University Limerick Hospitals Group had such a low ratio of consultants. In total, the group only had 230 consultants at the time, meaning it trails very far behind all the other hospital groups, which, on average, have between 600 and 700 consultants.

Why is the mid-west region being treated so unfairly in the allocation of resources? We still have not had an answer from the Minister to that question. In many ways, he is in denial about it. How can this postcode lottery be justified any longer? It cannot be justified. I note that a step-down facility has recently been opened in Nenagh, which was supposed to be a community nursing home. Another step-down facility is planned for Ennis but serious questions remain about it. I understand that in Ennis, similar to Nenagh, beds for local long-term care and respite are now to be converted to step-down beds for UHL patients. That is just robbing Peter to pay Paul. This provision is being sold as an increase in beds but it is not that at all. According to an HSE regional profile of the mid-west, the largest community healthcare network in the mid-west region is in west Clare, with a population of almost 79,000 people. Yet, Ennis General Hospital only has 50 beds. Clearly, that is not a fair allocation of resources. I accept that an additional 48 inpatient beds are planned for Ennis General Hospital, and that is welcome, but it could be up to four years before they are delivered.

What happened to the plans for 24-hour medical assessment and minor injury units in Nenagh, Ennis and St. John's hospitals? In March, Bernard Gloster said he was awaiting sign-off from the Cabinet. However, in response to a parliamentary question from me last July, the Minister said he had no plans to expand those services to 24 hours. Is the extension of services going to happen? Can he explain why he seems to have reneged on his earlier commitment? Without a model 3 hospital, an 8 a.m. to 8 p.m. service that does not even treat under-fives is simply insufficient to meet local need.

Another factor which must be considered is the age profile of this region. The mid-west region has a comparatively older population. The 75-to-79-year-old age group increased by almost 40% between 2016 and 2022, while the 85-years-and-older age group increased by 25%. As a result, there is an increased need for home care services. This is reflected in the home care waiting lists, with the mid-west accounting for 16% of the total national waiting list at the end of May. A total of 347 people were waiting for a carer to be assigned in Clare, with a further 285 people in Limerick and 110 in north Tipperary. This must be dealt with. We know that home care provision is particularly strained in rural areas, but that will never be addressed without increased hours, paid mileage and a statutory right to home care.

There is also a serious issue around access to GPs. Will the Minister please provide this House with an update on his strategic review of general practice? We should not have to wait any longer for that. It is urgently needed.

Separately, the continued absence of specialist eating disorder services in the region is completely unacceptable. When the current Taoiseach was Minister for Health, he promised 20 specialist beds by 2023. What happened to those? What happened to that promise?

Finally, the mid-west, like the rest of the country, is still dealing with the negative impacts of the recruitment freeze and continuing constraints on hiring. This is compromising safe staffing levels and patient care. There is a major problem with the lack of adequate resources in the mid-west region, and there has to be political responsibility for that.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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We go now to People Before Profit-Solidarity. Is Deputy Boyd Barrett sharing with Deputy Mick Barry?

Mick Barry (Cork North Central, Solidarity)
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Yes - three minutes and seven, a Cheann Comhairle.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Not a very equal spread.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Quality, not quantity.

Mick Barry (Cork North Central, Solidarity)
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In 2009, the emergency departments at Ennis, Nenagh and St. John's in Limerick were shut down under the Fianna Fáil-Green Party Government. They were downgraded to minor injury units. This arrangement has been kept in place by the Fine Gael-Labour Party Government and successive governments since then, leaving the only model 4 hospital in the entire region at University Hospital Limerick. These cuts were opposed by the vast majority of people in the region, many of whom said they would result in disaster - and how right they were. The people of the region have taken their opposition to these cuts and their support for properly resourced health services in their communities to the streets on more than one occasion. Five thousand people marched the streets before Covid. More than 10,000 people marched the streets after the death of Aoife Johnston.

Government policies have resulted in massive overcrowding at University Hospital Limerick, the shutdown of the emergency departments in the other hospitals and a lack of resources put in to compensate. A nurse at Aoife's inquest said that at the start of her shift that night there were 153 people waiting for treatment. The independent investigation by Mr. Justice Frank Clarke said that Aoife's death was almost certainly avoidable. It went on to say that the emergency department was in such confusion that there was no reality to the care plans that night.

The Minister has said he wants to inquire into the idea of a model 3 hospital in the region. Sinn Féin in this motion is calling for a model 3 hospital in the region. I spoke this afternoon to hospital campaigners in the mid-west who expressed disappointment that it has taken Sinn Féin 15 years, until the eve of an election, to come to this conclusion. One of those campaigners, Melanie Cleary, whose daughter died just hours after being discharged from UHL in 2019, said that this motion does not go far enough and that emergency departments in Ennis, Nenagh and St. John's need to be reopened.

It is clear that the policy of successive governments on this issue has been a disaster. There is a need for a reversal of cuts and a need for radical change. This motion does not go far enough in that regard.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank Sinn Féin for bringing forward this motion, which I am happy to support. I will not get into the discussion about whether it goes too far or far enough other than to say I bow to the knowledge of people in the region, whether they are campaigners or political representatives, who I am sure know a hell of a lot more than me about the details of what is happening to the health services in that area.

I am sorry you are going, Stephen. I had some important points to make to you. Anyway, he is gone.

Mick Barry (Cork North Central, Solidarity)
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He is back.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Good. Fair play to you, Minister.

I support the motion. The case of Aoife Johnston, her tragic and unavoidable death, should be a wake-up call for everybody. Something like that should not have happened. It is absolutely tragic and no doubt linked to massive overcrowding and the fact that she was left on a trolley for 13 hours without the medication she needed to save her life. Her life almost certainly could have been saved with that medication, without that overcrowding and without that chaos in the emergency department. It is an indictment of our health service that something like that can happen.

I am acutely aware that, week in, week out, the crisis in the emergency department in UHL is raised. From my point of view, the arguments that are made in this motion are eerily similar to the arguments that were made when St. Michael's Hospital and Loughlinstown hospital emergency departments were downgraded, supposedly as part of a project to develop a centre of excellence in St. Vincent's Hospital as part of a hospital group. All that has happened since is that, on a regular, ongoing basis, St. Vincent's faces a similar crisis of people left for hours and hours, and sometimes days, on trolleys. It happens regularly. The project has not worked.

The point I want to make to the Minister before he goes is that, while I am not a health spokesperson and do not, week in, week out, deal with him on the details of what is going on in the health service, I am very aware that the Government announced a lifting of the recruitment embargo in July of this year. Health workers had said the embargo was seriously inhibiting their ability to recruit the staff they needed in understaffed hospitals and other areas of our health service. Over recent weeks, unprompted, I started to get a series of desperate phone calls from staff members of all different grades in St. Michael's Hospital. They said the staff were utterly demoralised and patient safety was being seriously compromised in St. Michael's Hospital, that people were being pulled from one place into places they should not really be in order to fill gaps in every area of the hospital, that physios were not available for people on the wards or were being pulled from one place to another and that there were problems among the staff in catering, nursing and so on, people panicked and demoralised and saying that, despite their understanding that there was a lifting of the recruitment embargo, an effective embargo, a staff ceiling or staff quota, called the pay and numbers strategy, had in fact been imposed in June. I had not heard about this.

I have raised this with the Minister. He is saying we have to have some kind of control on recruitment and all the rest of it. I heard the same issue from the National Rehabilitation Hospital, NRH, when I attended the opening of the new wing. I said to the people in the NRH I had been hearing about this pay and numbers strategy in St. Michael’s Hospital and the impact it is having on staff and patient safety. When I asked the people in the NRH about this, they said it is exactly the same there. I phoned the INMO to ask whether its representatives had heard about the pay and numbers strategy. They said they had and it was endangering patient safety across the health service. An embargo by another name is being imposed under the pay and numbers strategy, whereby ceilings have been put on recruitment based on who was in post in December 2023.

I was absolutely shocked when I heard about a particular case. I met the representative of the public health nurses in my area at the INMO briefing and she said there were a significant number – I think she said 11 but the Minister can correct me if I am wrong – of community public health nurse posts which had not been filled at that point and have now just gone. They have just gone. This is the impact of the strategy. This is happening in St. Michael’s Hospital and elsewhere. This is absolutely crazy. Arbitrary staff quotas and ceilings are being imposed with the consequence that patient safety is being seriously endangered and the workforce in the hospitals is absolutely demoralised. I cannot overstate how demoralised the workforce is. We are organising a public meeting, which the Minister or a representative of his is welcome to attend, in our area in the next couple of weeks to discuss this, prompted by the concern, demoralisation and panic of the workers in the hospital.

I was contacted by people in St. Luke’s Hospital who have asked me to ask the Minister directly whether he is going to act on the national radiation therapist review report and recommendations. They say huge numbers of machines, scanners and other equipment to treat cancer are sitting idle and not being used across the country, including in St. Luke’s Hospital, because of lack of staffing, due to staff quotas or whatever being imposed. We cannot endanger patient safety by arbitrary staff quotas, ceilings, embargoes or whatever name you want to put on them. Staffing has to be based on patient safety.

Seán Sherlock (Cork East, Labour)
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We move to the Regional Group and Deputy Canney, who is sharing time with Deputies Lowry and Tóibín.

Seán Canney (Galway East, Independent)
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The issue of University Hospital Limerick is very concerning for everyone. While I am not from Limerick and it is not in my area, I agree wholeheartedly with Deputy Boyd Barrett that there is an artificial dumbing-down of figures of employment. It is like a puzzle, trying to figure out what is actually happening with recruitment in the HSE. It is completely different from what is being portrayed in the public eye.

Reconfiguring all the hospitals and making centres of excellence in Galway, Limerick and wherever else was a great plan, but it never really got to the place where things were being done about it. We are still awaiting a paternity unit in Galway. We are looking for a paediatric unit and a new emergency department. Although a temporary emergency department was built approximately four years ago, we still have not gone for planning permission for the new emergency department. We need a new cancer hospital, beds and investment of approximately €1 million in infrastructure alone on the site if we are to be serious about having a centre of excellence in Galway to serve more than one million people in the region. It is not happening at the pace we need it to happen, however.

The Minister of State, Deputy Butler, was in Tuam when we opened the community nursing unit. I said to her in the Dáil before that it is nearly a year since she was there but half of that community nursing unit is still not open because of something going on between HIQA and the HSE. There are 25 empty beds in that place, with probably 25 people in Galway hospital holding onto beds. This is a year later. There was a total of €17 million investment, including €7 million investment from a trust. That is what we are delivering to people.

Day centre services, which were in the old nursing unit in Togher More and were waiting to go into the new place, still have not commenced in the new community nursing unit. The reason given for this is that there is some problem with a door. For God’s sake, we need to have a wake-up call about how we are doing our business and the processes by which we are doing it because we are spending a hell of a lot of money on absolutely nothing.

Michael Lowry (Tipperary, Independent)
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University Hospital Limerick is an ongoing serious problem. There is massive difficulty relating to overcrowding and poor delivery of service. There is obviously a problem with bed capacity, staff numbers and patient care. The hospital serves the constituency I represent in north Tipperary. Daily, and almost hourly, I receive calls from people complaining and giving out about the experience they had in UHL.

Recently, the Minister announced HIQA would start a review to see if a model 3 hospital was required. It is evident and obvious to everyone in the mid-west region that we need a model 3 hospital. The only question to be determined is the location of it. What is the time frame for HIQA to report on this? It is not something we can put on the long finger. When I hear the word "review", it immediately instils in the mind the impression that this is being put on the long finger. It is a matter of urgency that we get the level 3 hospital and an additional emergency department to serve the mid-west region.

The Minister also announced recently - I agree with this in principle - that our medical assessments units should be open for longer. In Nenagh, that was approved, funding was approved for it and recruitment has started. When I met with representatives of the hospital, however, I found the slots that are already available are not being filled because GPs are not referring patients to the unit in Nenagh. Rather, they are actually referring them to Limerick. The idea of the medical assessment units in Nenagh and Ennis is to avoid overcrowding at the emergency department at UHL. The first thing to do, before any announcements are made, is to ensure there is consultation with the nurses and the staff in these hospitals. They are the people on the front line who know exactly what is required and needed. They are actually being ignored, however. They should be central to the decision-making process but at the moment they are being sidelined.

As for mental health services in north Tipperary, and Tipperary in general, a former Minister of State, a member of the Labour Party, closed St. Michael’s psychiatric unit in Clonmel. At the time, we were told we would get an acute bed complement at Nenagh Hospital. That did not happen. We now have a situation in which patients from Tipperary have to travel through Nenagh and Limerick to arrive in Ennis, only to be told the unit in Ennis is overloaded and overcrowded and that the facility is not available to them. Many patients from north Tipperary have been asked to return home because there was no bed available for them or the consultant could not see them. North Tipperary needs a mental health acute bed complement. I ask the Minister of State to examine that possibility.

Peadar Tóibín (Meath West, Aontú)
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I wish to express my deepest sympathy to the family and friends of Aoife Johnston. Her death was a catastrophic disaster for her family and friends. Aoife was 16 years old when she died. Incredibly, she had to wait 12 hours in hospital before receiving treatment. Reading the report issued by Mr. Justice Clarke, it is incredible what happened in that situation. Aoife was triaged as a category 2 patient, meaning she should have been seen in ten minutes. However, due to the volume of patients in that location, it was ten hours before she was actually seen.

Even when she received her appointment with the doctor, it took a full hour for the antibiotics to be given to her. Sepsis can be treated very simply with antibiotics. In 2022 in Ireland, antibiotics that would have saved Aoife's life were withheld from her. That is an absolutely disastrous situation under the current Government. Mr. Justice Clarke's report is incredible in how it speaks about this. It refers to the emergency department as grossly overcrowded, with a complete lack of clarity on sepsis protocols. It goes on to state there is a risk of recurrence. Therefore, it is not that we have learned from what has happened in the past and made sure it would never happen again; it is that there is currently a risk that it could happen again in the exact same location. That is a damning indictment of the management of the hospital from the Government's perspective.

It is really important to state that the current overcrowding in hospitals is a direct function of Government actions. The Green Party and Fianna Fáil closed Ennis and Nenagh hospitals in 2009. They made a decision to close down those hospitals even though the Horwath report stated there was not enough capacity at UHL to deal with the additional patients who would go there. There was a reckless decision made by the Fianna Fáil–Green Party Government in 2009 to close the hospitals. Everybody is talking about accountability at the moment but I do not see any in these decisions.

What really frustrates me, as chair of the Save Navan Hospital campaign, is that exactly the same efforts were made to close Navan hospital in the same period. Indeed, HIQA had a hit list of nine hospitals that it sought to close. It was dressed up by the Government that this was being done for the best possible reasons, namely that there could not be a hospital at every crossroads, that we were going to have centres of excellence and that the patient would be safer in the long run. That is certainly not the case. There were no centres of excellence created; there were centres of trolley counts created. No extra resources were put in place to deal with the additional people coming from the affected locations. Right now, it is HSE policy, in black and white, to close Navan hospital emergency department. That is the current policy of the Government. Not only has it learned nothing about extra capacity at Limerick hospital but it is still the Fianna Fáil–Green Party policy to close emergency departments in this State. This is quite horrendous. We thank our lucky stars in Meath that tens of thousands of people came out in their droves, in march after march. Our area would be in exactly the same position as the mid-west region if it were not for the campaign.

Mary Butler (Waterford, Fianna Fail)
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Let us be fair: the Minister, Deputy Donnelly, stopped that from happening.

Peadar Tóibín (Meath West, Aontú)
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The Minister, Deputy Donnelly, facilitated the closure of Loughlinstown ED as well. He bought into the lie that existed that the closure of EDs would somehow make people safer. It certainly has not, and the Government needs to apologise for the closure of the EDs.

Mattie McGrath (Tipperary, Independent)
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Yes, Aoife Johnston's death at UHL was almost certainly avoidable. What is happening day in, day out at UHL presents a shocking, appalling vista, all because the Government closed down Nenagh, St. John's and Ennis emergency departments and expected UHL to do the work without putting in place the necessary beds or staff.

I heard the Minister of State, Deputy Mary Butler, quipping across the floor to Deputy Tóibín that the Minister, Deputy Donnelly, saved Navan. Why did she not save St. Bridget's in Carrick-on-Suir, at her back door? Again, this is an appalling vista. She closed the hospital with hospice beds and piddled on the people of Carrick-on-Suir and her own area, Portlaw, County Waterford, and south Kilkenny. Shame on you. Shame on the Government over the way the health service is being run. It closed St. Michael's, the mental health service in Clonmel, and every second week unfortunate people take their own lives because there is no place to go. People must go into a crowded emergency department.

With regard to the mid-west, I heard the CEO say on radio on Sunday that there would be repercussions and discipline. The discipline is that the Garda should be investigating manslaughter, at the very least. People should be charged with manslaughter, if not worse, because there was absolute neglect, uncaring behaviour and absolute bedlam. I do not blame the nurses and the ordinary people on the ward trying to do their best because this has been ongoing, day in, day out, affecting people in north Tipperary who have to go up there. They are coming down to Clonmel and going anywhere but Limerick. Limerick now has a name as somewhere with systemic issues and bad management. The Government is afraid to tackle senior management and there is cover-up after cover-up. This is not fair and not good enough for the people. There is no accountability whatsoever. There is none regarding the children's hospital – you name it. There are absolutely zero consequences for people who neglect. Minister of State, Deputy Butler, the Minister, Deputy Donnelly, Minister of State, Deputy Rabbitte, and the other junior Ministers should take the blame and accept responsibility. They like taking the credit, so they should take the blame when they should.

Michael Healy-Rae (Kerry, Independent)
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To break away from the subject for two seconds and to break the ice a small bit, I thank the Minister of State, Deputy Butler, for her direct work on, interest in and genuine concern for Ocean View nursing home in County Kerry. I will not go into detail but just wanted to thank her on the record. I acknowledge and appreciate her genuine interest – I really do – and so does everybody at the nursing home. All I ask is that she keep up this work and try to get the HSE to follow up. I thank the Chair for his indulgence.

Let me refer to Limerick hospital. I purposely spent a night in the ED in Limerick because I wanted to see at first hand what it was like. Yes, it was chaotic, but it was not the fault of the nurses or doctors on duty. It was because of the massive numbers of people going through it. That is no excuse for events that have happened there. We cannot blame individuals; we have to look at ourselves as politicians, the Minister for Health and the Department of Health. It is not a matter of pointing a finger at the staff below in the hospital and their extended families, who go to work, roll up their sleeves and try to help in an awful situation. We have to acknowledge their work. There are people in the hospital who are really trying their best and they are so frustrated. They do not want to hear their hospital talked about in a bad way, but, yes, there are problems and it is up to us as politicians, the Department of Health and the HSE to address them. We should always remember that the buck stops with the Minister. Meaning absolutely no disrespect to the Minister of State, I must ask where the head Minister for Health is. I understand other people are here, but it is wrong that he is not here.

Michael Healy-Rae (Kerry, Independent)
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I am sorry to hear that. It is a shame.

Danny Healy-Rae (Kerry, Independent)
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I support Sinn Féin's motion. Like everyone else, I was horrified by Aoife Johnston's death. As I said at the time and since, I honestly believe that those culpable for her death or neglecting her should be brought to book – no question about it. They should pay a price of some kind, depending on the seriousness of their neglect, for what they did not do.

I am very worried about issues with health services in Kerry. I have mentioned some of these today. Nurse posts are not being filled in Kerry. I have worked out that there are 120 beds idle in Kerry because nurses have not been appointed to fill the associated posts. Owing to the HSE's safe-working plan, it cannot operate a bed if it does not have nurses. I raised this with the Minister for Public Expenditure, NDP Delivery and Reform, Deputy Donohoe, today and I want it addressed.

Someone who gets sick on a weekend is in a very vulnerable position because many doctors are missing from where they should be. That is not good enough. We take people to the north of Ireland to get their cataracts removed. The staff are working around the clock, seven days per week, and we should be able to pay people to do the same. We are not blaming the people we have who are working and doing their best at the coalface every day. They are being let down by the HSE, which is not putting money in at the coalface.

Richard O'Donoghue (Limerick County, Independent)
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Since the start of this Government's term of office, I have been talking about accountability. The Rural Independents were the first people here to raise the issue of UHL and the management structure there. New management has been put in place. In the interim, Jessica Sheedy and Aoife Johnston both died. How many more died? There has been poor management in this hospital. I am not going to mention the name of the CEO, but there is only one CEO. The damage that person has caused to the hospital and to the hard-working staff there is nearly irreversible. Staff have been bullied out of their jobs. How many are on long-term stress leave? How many have left the hospital in the past month? Nurses have left because they were being bullied and forced to cover up things they did not want to cover up. If they came out and said what was happening, their jobs were put in jeopardy.

Seán Sherlock (Cork East, Labour)
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Deputy, can I just say-----

Richard O'Donoghue (Limerick County, Independent)
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Once I get my time on the clock, the Cathaoirleach Gníomhach can say what he likes.

Seán Sherlock (Cork East, Labour)
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I am very happy to give the Deputy his time on the clock. However, I am a voluntary Chair and he is making assertions about a particular person. Because I am a voluntary Chair, I do not feel equipped, nor are any of my colleagues who chair voluntarily, equipped to be able to deal with the assertions he is making. On that basis, I am calling for the suspension of the House to allow for the Leas-Cheann Comhairle or the Ceann Comhairle to come in and deal with these issues.

Richard O'Donoghue (Limerick County, Independent)
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I will be delighted if they come in.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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We will resume. Deputy O'Donoghue is able to clarify that while he was raising issues of grave concern to him, he was not attributing any blame to any identifiable individual. Is that correct?

Richard O'Donoghue (Limerick County, Independent)
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That is correct. As there are live investigations at present, I would not like to target any one individual in the context of the matters that are being investigated. I am so delighted that after five years of being here that UHL is finally being investigated. When the investigations are done, I hope criminal charges are brought against the people who have put others at risk and that there is accountability across all sectors if wrong has been done. It is for the protection of lives. If I have to get into hot water over standing up to protect lives, I have no problem with that. I will do that all day every day.

The criminal investigation needs to go ahead. If they stop people from giving evidence or reporting the issues, those people need to be held accountable as well under the investigations going forward. I thank the Ceann Comhairle for coming back to the Chamber and giving me the time to clarify matters.

Michael Collins (Cork South West, Independent)
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I wish to express my sympathies to the family of Aoife Johnston and the families of many others who died in terrible circumstances.

I support the motion. Those in our group have continuously highlighted serious concerns about the chronic overcrowding at UHL for several years, especially my colleague from Limerick Deputy O'Donoghue. The Minister for Health's neglect of this emergency has left many patients without necessary care, and some have died. Day after day, we witness delays in care for numerous elective patients, as numbers at UHL's emergency department have spiralled and reached an unacceptable level. There were 80,133 emergency department attendances in 2023, which is an average of 219 per day. UHL is the most overcrowded hospital in the country. This is not a new problem, yet no improvements are evident. This year, in fact, matters are worsening.

We saw it last week in the Cork-Kerry region, where the National Ambulance Service tried to cut our ambulance services. The Minister had to step in and have the decision reversed. It is easy to know that an election is on the way. Would that have happened if there was not? That is the question. The problem we have now is that patients, many of whom are elderly, need long-term bed care cannot get it in either community hospitals or nursing homes. This is happening in my constituency, and I heard another Deputy refer to it earlier. People cannot get beds. Numerous people are begging to come out and their families have been told to take them out of the medical units at Bantry General Hospital and other hospitals. However, they cannot get either nursing home or community hospital beds because we have not invested. While we have invested in improving community hospitals, we have not invested in increasing bed capacity in situations where our ageing population is increasing. We have a crisis situation.

In west Cork, we lost Belgooly nursing home. Deputy Healy-Rae was praised, but we got no help with Belgooly, other than to get the patients out as fast as possible. It was like they were hit with a brush in an effort to get them into other nursing homes. It was a case of their being put anywhere - it did not matter if a loved one lived next door to them. The families had to accept it. If they did not, they took their loved ones home. That was what they were told in Belgooly, and it was terrible. Now, 18 months later, there are all sorts of rumours about what is going to happen to the building there. That facility should have been taken over by the HSE. That was the opportunity. It would have been a fantastic investment and it would have guaranteed beds for elderly people. It is the same with Bantry nursing home, which was under Aperee and which is now in the hands of a very good receiver that is very good to its staff, patients and their families.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Thank you, Deputy.

Michael Collins (Cork South West, Independent)
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That individual is doing his best to make sure that these people have a home and that it is the same home they always had. We have a crisis here that needs to be looked at on a deeper level. It has not been looked at. It has been neglected and is causing major concern in my area.

Violet-Anne Wynne (Clare, Independent)
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From reading this motion, one thing is absolutely clear: an election is coming. There is a clear omission of the usual Government rhetoric of requiring clinical advice. What happened? Have those on all sides of this House finally conceded that the writing is on the wall or is it the case that, as the saying goes, even on the dogs on the street know that the mid-west needs an additional emergency department and that the statistics speak for themselves? Attendance at UHL is up 7.2% compared with last year. It has also been consistently the most overcrowded hospital in the country throughout the lifetime of this Government. UHL has seen increased pressure, including an 11% increase in patients over the age of 75 and a 20% increase in patients on trolleys during 8 a.m. checks. Surge capacity in UHL was triggered every day of last year. There is no person who has stepped foot inside that hospital who would not describe the situation there as "chaotic".

It is also important to note that when an elective surgery is cancelled, it is not reinstated in Ennis as quickly as it is elsewhere. Why is that? It is because a quarter of UHL presentations are Clare-based. The whole mid-west is feeling the pressure in UHL. People in Clare are the ones being asked to live with no alternative model 3 emergency department. There is no such service within 45 minutes for much of the population, and there is no end in sight. Clare is the only county in Munster with no access to an emergency department. What are we to the Government? Are the people of Clare the poor cousin's aunt?

UHL has 13% fewer beds than the average model 4 hospital and is expected to care for more than 431,000 people without a second supporting emergency department. Let the suffering speak for itself. We have lost countless lives needlessly. Poor Aoife Johnston died at only 16, which was far too soon. The Government of the day doomed UHL to struggle such that it has become a centre of chaos, which is a far cry from the centre of excellence that was promised. Can the Government stop making promises and putting things off until tomorrow and just be a Government of today?

Mary Butler (Waterford, Fianna Fail)
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At the outset, I wish to offer my heartfelt sympathies and condolences to the family, friends and community of Aoife Johnston on the death of a beautiful young girl. I cannot even begin to imagine their loss.

The Government recognises the challenges in health services in the mid-west region and the distress these have caused to patients, their families and staff. From the start, this Government has recognised the need for investment in healthcare in the mid-west region. The increase in hospital budgets, the significant capital investments and the significant increase in staffing in all hospitals in the mid-west are testament to our commitment to facing these challenges. However, it is a combination of both capacity and reform that will make the difference for the people of the mid-west. With the establishment of the new health regions, and the appointment of Sandra Broderick as the new mid-west regional executive officer last December, this Government is overseeing significant reforms.

With significant investment in both acute and community services, these reforms are realising the vision of an integrated health service.

This Government recognises the important role the whole health system in the mid-west plays in reducing the pressure on UHL's emergency department. We are delivering improvements in public health, enhanced community care, diagnostics for GPs, care for older persons, additional primary care centres, and enhanced pharmacy services.

A common theme in both the independent investigation by the former Chief Justice, Mr. Frank Clarke, and the expert support team assigned to UHL in May is the need for reform in working practices at UHL. Mr. Justice Clarke identified a number of factors that contributed to delayed treatment and the tragic death of Aoife Johnston. These are extremely serious and concerning findings. Reform is essential and must not be delayed. The HSE’s chief clinical officer, Dr. Colm Henry, is setting up a structure to oversee the immediate implementation of all of the Clarke report recommendations. The expert support team has also identified a range of changes in working practices that need to be implemented to improve patient care.

The Minister for Health has funded a comprehensive package of measures aimed at alleviating pressure in the hospital. In April, he announced a series of additional investments and reforms to reduce pressure on the emergency department at UHL. These include: accelerating the building of two new 96 bed blocks on the UHL site; commissioning 16 additional fast-build beds on site, with construction anticipated to be completed by the end of 2024; procurement of 20 additional step-down transition and rehabilitation beds in Clare; extending opening hours of the region’s three medical assessment units to 24-7, from 12 hours a day, seven days a week on a phased basis, which is currently being progressed; making UHL one of two national test sites for acute virtual wards; and providing GP and advanced nurse practitioner on-the-door services at the UHL emergency department for cases that can be streamed to primary care.

At the same time, the CEO of the HSE directed a number of reforms in the delivery of services in the mid-west, taking from measures that have been successful in reducing overcrowding at University Hospital Waterford. These include senior decision-makers being rostered on site at UHL, both in the emergency department and throughout the hospital, after hours and on weekends. Deputy Cullinane and I know these measures work because we are very familiar with University Hospital Waterford. What is being done also includes an all-of-hospital approach to treating emergency department patients. This involves: the use of non-emergency department consultants to support emergency department colleagues; senior management in the UHL emergency department in early mornings; a targeted campaign to increase the number of consultants at UHL on the public-only consultant contract; a strong patient flow team in place at UHL seven days a week as part of a single mid-west bed management system and patient flow; weekend access being extended to scheduled diagnostics for the emergency department; increasing community and health and social care professionals support for weekend discharges; a social inclusion hospital-to-community team to tackle the demographic and social challenges which lead to overuse of hospital pathways; and a CAMHS paediatric liaison team to provide in-reach to the paediatric wards to support children with mental health needs.

In May, the Minister published the acute hospital inpatient bed capacity expansion plan. Overall, the projects detailed in this plan will increase bed capacity at UHL by up to 292 beds by 2028. In total, 542 new inpatient beds will be delivered in the region by 2031. In May, the Minister also announced an update on the rapid progression by the HSE in constructing surgical hubs, which will open to patients this year and next year across the country to deliver more elective day-care procedures. A site has been identified for the Limerick surgical hub at Scoil Carmel. When fully operational, each hub is expected to deliver approximately 4,000 additional day-case procedures, 5,800 additional minor operations and 18,500 additional outpatient consultations annually.

These additional projects sit alongside a significant programme of capital works across the region to ensure that the infrastructure is in place to meet the needs of those accessing our health services. A new blood science and pathology facility is currently in detailed design phase at UHL. Enabling works are ongoing to reconfigure and extend the current UHL radiology department and provide an additional MRI. Work is ongoing to provide kitchen, catering and fire safety upgrades to existing UHL buildings. Following the opening of a new €2 million injury unit at Ennis Hospital in 2022, a new theatre block is currently in detailed design phase at the hospital.

At the same time, as has already been underlined, this is a health region that has seen a significant increase in resources under this Government. The budget of UHL has increased by 59%, an additional €158 million since 2019, from €265 million in 2019 to €423 million in 2023. Investment in the hospitals in the region has increased by 58%, an additional €213 million, from €369 million in 2019 to €582 million in 2023. Some 150 new beds have been opened in the University of Limerick Hospitals Group since January 2020, and 108 of these have been in UHL. Staffing at UHL has risen by 41%, an increase of 1,167 whole-time equivalents since 2019, with 3,981 staff in place in July 2024. Safe staffing has been fully funded in UHL. It was implemented on 13 medical and surgical wards, and on the acute medical assessment unit in 2023. Extension of safe staffing to all inpatient wards at the hospital will be complete by the end of the year.

To deliver all of these capacity improvements and reforms, the Minister and his officials have had significant and sustained engagement with the HSE on the challenges in the mid-west region. The Minister has visited the hospital and the region on numerous occasions. It is a combination of capacity and reform that leads to better access for patients.

This Government is determined to continue progress in the mid-west by adding more beds, diagnostics and theatres, hiring more healthcare professionals, rolling out enhanced community services, modernising working practices and improving patient flow to ensure the services needed are available when patients need them. The people of the mid-west deserve access to responsive urgent and emergency care, and that is what this combination of new capacity with much-needed reform aims to deliver.

David Cullinane (Waterford, Sinn Fein)
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The Government is not opposing the motion, is that correct?

Mary Butler (Waterford, Fianna Fail)
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Correct.

David Cullinane (Waterford, Sinn Fein)
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I thank the Minister of State.

Mary Butler (Waterford, Fianna Fail)
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I am sorry. I thought the Minister had clarified that we are not opposing the motion.

David Cullinane (Waterford, Sinn Fein)
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I thank the Minister of State.

First, I welcome the fact that since the three emergency departments in Ennis, Nenagh and St. John's were closed, this is the first time the Dáil has passed a motion saying that a second emergency department and a second model 3 hospital are needed for the mid-west. I think that is significant. There is a HIQA review that will look at this. That review needs to focus on where the best location is and what the best hospital is to deliver that second emergency department.

I have been in the mid-west probably more than any other region, in the context of visiting hospitals and healthcare settings, since I took the post as Sinn Féin spokesperson for health. I have been in UHL four times, once with the Oireachtas health committee and three times on my own, meeting with hospital management and clinicians. I have also met with campaigners in the region. I have met with healthcare professionals and healthcare trade unions. With respect, there have been different options put to me as to what should happen in the mid-west. Some campaigners and individuals have said that we need four emergency departments in the region. Some have said we need a second emergency department in the region. Some have said we do not need an additional emergency department and what we need is to put capacity into UHL. We do, however, have to land on what is safe for the people in the mid-west, however. We have to have a plan, in the first instance, that is safe, because what is happening is not safe. We have to look at population growth and the fact that we have an ageing population and ensure that we are providing the healthcare services needed for people who live in the mid-west. We also have to have a clinical underpinning of all of the decisions we make. That is accepted across the House.

I hope that everybody in the Oireachtas accepts that there is a compelling case to not just put capacity into UHL but to look at what is happening in other regions compared with what we have in the mid-west, and acknowledge that there is a need for a second emergency department and a second model 3 hospital.

The Minister of State mentioned University Hospital Waterford. We are all proud of the advances that have been made in the emergency department there. It is not that the hospital is perfect and it is not the case that there are not issues there. When we refer to how successful it is, I instantly get messages and calls from people who say, "Hang on a second, I have not had the best experience" or "I have been left waiting in the hospital". They are maybe not on hospital trolleys but they have been left waiting on a chair for far too long in the emergency department.

It is far from perfect but it is certainly better than it was and it is certainly one of the better-performing hospitals. I am fortunate enough to live in the south east. The people in the south-east region have access to three emergency departments. If you live in the south east, you have Wexford General Hospital, St. Luke's hospital in Kilkenny and University Hospital Waterford. I do not think anybody in the south east, whether from Waterford, Tipperary, Carlow, Kilkenny or Wexford, would accept it today if any Government said it was going to close one or two emergency departments in the south east and that everybody should go to Waterford.

After we had the fire in Wexford General Hospital, people from Wexford had to go to Waterford. It put enormous pressure and strain on the hospital in Waterford. It was the first time that we saw real pressures in the emergency department, because we had to take the overflow, rightly so, of patients coming from Wexford. I do not think I, as a person who lives in the south east, can tell people who live in the mid-west that they have to continue with one emergency department or one model 3 hospital.

We need to look at how we scale up capacity. How do we scale up the capacity of University Hospital Limerick? All the beds that the Minister promised are needed. In fact, I would say we need more. I am also conscious that as Mr. Justice Clarke said in his report, the site in Limerick is coming to full capacity. The opportunities to advance emergency care, acute care and hospital care in the mid-west region will have to come from elsewhere, whether additional sites in Limerick or scaling up capacity in other hospitals. I also believe that we need to look at elective care in the mid-west region. I know the Minister is talking about a surgical hub that will be in the Limerick area but this State, as the Minister of State knows, is committed to a number of elective-only hospitals. The locations have been chosen, yet we are not even at the starting gate in reality for most of them. I know there will be such a hospital in each of Galway and Cork and potentially two in Dublin. We are still waiting for sites to be identified in Dublin. We need to accelerate those. I believe we need to look at some sort of elective facility in the mid-west region and in Limerick. One of the big problems in all emergency departments which causes many of the problems is a clash between scheduled and unscheduled care. I looked on in horror when the people of the mid-west had almost all their elective procedures cancelled for the month of August and a bit longer than that. There was a wholesale cancellation of elective procedures. It caused consternation for the people who lived there. They were waiting for their appointments, had appointments scheduled, and they had to be cancelled because of the overcrowding in the emergency department.

I also read and have seen all the media coverage of the inquest into Aoife Johnston's death. It was absolutely tragic, heartbreaking reading. The parents of Aoife were comforting her when she was in the hospital and were telling her that she was in the right place. We now have a report from Mr. Justice Clarke, who said that not only was she possibly not in the right hospital, but even within the hospital itself, she was in the wrong area and the wrong section of the hospital. How heartbreaking is that for any family? A beautiful 16-year-old girl was left for 13 hours without getting the healthcare she needed. That report has made recommendations and outlined the challenges in the mid-west region. It clearly brought us back to that moment in 2008 and 2009 when services were closed on the promise that a centre of excellence would be built in the hospital in Limerick, which has not happened.

I am proud of my record of consistently calling for services in the mid-west that are safe, clinically underpinned and serve the people of the mid-west region. I have been asked about this on more than one occasion and have always answered that if I was Minister for Health, in a heartbeat, I would deliver a second emergency department if the clinical advice was to do it. We now have a HIQA report. That needs to be expedited. We need to see the findings of that published as quickly as possible. It has to do its work but I believe that report will be valuable. I hope that report will look not at whether there is a need for a second emergency department, but at where it should not be. I am putting my position on the record that I do not believe the region can sustain four emergency departments. We have to look at what is possible, viable and safe. We also know that emergency departments in model 3 hospitals require critical mass. They require volume. To operate safely, you have to have that. To attract clinicians and make sure there is the patient throughput, as well as specialists who can work in those hospitals, that has to be put in place.

I believe there would be significant progress for the mid-west if we can get the capacity into Limerick, including the additional beds, the 24-hour urgent care, and all of the primary and community care which is needed too, because that is as important as what is happening in the hospitals. If people do not have alternative care pathways, including care in the community, the option of homecare, rapid access to a GP, community intervention teams, chronic disease management teams or the integrated care programme for older people, ICPOP, or if those pathways are patchy, the problem is that people who should be treated elsewhere end up going to an emergency department. Part of the solution is also building up capacity in primary and community care and making sure those alternative pathways are present. It would be a big step forward for the mid-west region if we could sort the problems out for University Hospital Limerick. It would be a big step forward if we can finally start to plan. We can wait until HIQA recommends the location for a second emergency department or which of the hospitals in the region should be scaled up to a model 3. That will be a significant advance and will finally give the people of the mid-west region the safe and accessible healthcare services that they need.

We owe it to Aoife Johnston and her family. We owe it to all the others whom Deputy Quinlivan and others have named who have suffered in the hospital because of the lack of capacity. We cannot tolerate any part of the country where people do not feel safe going into their own hospital. It is intolerable that people do not feel safe in their own local hospital and that parents were comforting a 16-year-old, telling her that she was in the best place and was going to be looked after, and unfortunately, she died. As the report said, it was a death that was almost certainly avoidable. For her memory, for her family and for everybody who lives in the mid-west region, let us do what is right and deliver the healthcare capacity that the region deserves.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Thank you all. Congratulations to all involved.