Speech by James Reilly, T.D., Minister for Health – Private Members – Statute of Limitations (Amendment) Bill 2013 – Symphysiotomy
I welcome the opportunity to address the House today on this important issue. I am aware of the distress that symphysiotomy has caused to a number of women who underwent this procedure and recognise the pain and ill health they have endured as a consequence. I want to reassure the House that the Government is committed to dealing with the issue sensitively, so that it can be brought to an appropriate and fair conclusion for all the women affected by it.
For these reasons I have agreed to accept this Bill, although I have been advised that there are serious flaws in it and also that it may not achieve the objectives intended by Deputy Ó Caoláin. I wish to give a strong message to the women involved that I intend to help them get closure to this matter in the fairest way possible.
At the outset I would like to explain what symphysiotomy is, give some background and context about its use as a surgical procedure and specifically its use in Ireland. Symphysiotomy is a medical procedure that was primarily used before the advent of safe Caesarean sections. It was introduced into Irish hospitals to help women who had difficulty giving birth due to narrow or obstructed birth passages. The procedure was carried out in Ireland from about 1920 until the early 1980s long after it had been discontinued elsewhere at OLOL. It was gradually replaced by Caesarean section as the preferred method of delivery in childbirth, where required. A pubiotomy involved cutting the pubic bone rather than the joint of the symphysis pubis.
Occurrence of Symphysiotomy
A figure of 1,500 symphysiotomies has been estimated for the period 1944-1992, giving a rate of approximately 0.05% of all births in that period. While there was a large variation, even in the hospital with the highest rates, the maximum rate appears to have been 0.06% in any one year. It was a rare intervention, therefore, in comparison with caesarean section, which rose steadily from just under 2% of deliveries in 1944 to over 4% nationally in 1984. This is not in any way to minimise any serious after effects and suffering it had on many of the women concerned, but it indicates that the procedure was quite rarely carried out in Ireland overall.
Supports for Women affected
As Minister for Health, my first priority is to make sure that the health needs of those who have had a Symphysiotomy are met quickly and effectively.
With this in mind I am committed to ensuring that the greatest possible supports and services are made available to women who continue to suffer effects of having undergone this procedure. The women concerned continue to receive attention and care through a number of services which have been put in place by the HSE. These services include:
- the provision of medical cards to all who request them;
- the availability of independent clinical advice for former patients;
- the organisation of individual pathways of care and the arrangement of appropriate follow-up for women, including specialist triple assessment, medical assessment, gynaecological assessment, orthopaedic assessment, counselling, physiotherapy, reflexology, home help, acupuncture, osteopathy and fast tracked hospital appointments, where this is appropriate;
- the refund of medical expenses related to symphysiotomy in respect of medication/private treatments;
- a Support Group facilitated by a counsellor which was set up in 2004 in Dundalk and Drogheda for women living in North East region;
- the nomination of a National Lead Officer for Symphysiotomy in the HSE. In addition there are five designated regional liaison officers in place across the regions of the HSE.
The provision of these necessary support services for women is monitored and overseen by the Health Service Executive (HSE) which is committed to being proactive in offering help to women who underwent a symphysiotomy and who may wish to avail of these services.
Independent Research Report Commissioned
We need to act on the basis of the best evidence and advice that is available in relation to this issue, as in all aspects of our health services.
To this end the Chief Medical Officer of my Department commissioned an independent research report into the practice of symphysiotomy in Ireland in 2011. The aim of the report is to provide an accurate picture of the extent of use of symphysiotomy in Ireland, and an examination of the Irish practice relative to other countries. It will include an assessment of the circumstances in which the procedure was carried out, what protocols or guidance existed at the time for professional practice and details of when the practice changed and why.
The specific terms of reference the researcher has been given are to:
- Document the rates of symphysiotomy and maternal mortality in Ireland from 1940 to date by reference to available data (including annual reports and other reports);
- Assess symphysiotomy rates against maternal mortality rates over the period;
- Critically appraise international reviews of symphysiotomy practice and associated rates in a number of comparable countries in the world and in Ireland;
- Review any guidelines and protocols that applied in Ireland on symphysiotomy over the time period;
- Write a report based on the findings of the above analysis providing an accurate picture of the extent of use of symphisiotomy in Ireland, and an examination of the Irish experience relative to other countries.
The academic researcher concerned was formally appointed in June 2011.
Plan for the research report
The research report was conducted in two stages. The first stage was an independent academic research process that analysed available documentary evidence. The first stage did not include interviews with individuals directly involved in symphysiotomies (mothers, practitioners and midwives in particular). This approach was central to the production of an independent report, compiled without influence or input from vested interests.
The second stage of the research process was a consultation process on the draft academic research report. The consultation process directly involved patient groups, health professionals and in particular, the women who have undergone a symphysiotomy.
This second stage of the research took place during mid-2012. The consultation process was advertised to the public in the national newspapers and also through the cooperation of the symphysiotomy support groups, in order to reach as many interested persons as possible, particularly the women themselves. A number of consultations were held at different locations throughout the country. The sessions were conducted solely by the researcher. It was also open to interested persons to make submissions in writing or by email directly to the researcher. This second stage has just been completed by the researcher and the report has been sent for peer review, in line with best practice. It is expected that the report will be finalised and submitted to me in May, at which time I will examine it and consult further with government. It is intended that the finalised independent report will inform the Government’s overall consideration of this matter, including of any actions that may be required, and also any legal implications.
Statute of Limitations
The law concerning the limitation of actions is set out primarily in the Statute of Limitations Act, 1957, as amended. I understand that the Statute provides that a Plaintiff has two years from the accrual of the cause of action to bring a personal injuries action or two years from ‘the date of knowledge’ within which to institute legal proceedings. Consideration of these matters raises significant policy and legal issues, which have wide ranging implications. This includes the fact that the State has an overall duty, under the Constitution, to provide for the administration of justice in a manner which respects the principles of due process and strikes a fair balance between the rights of plaintiffs and defendants.
All options will be actively examined within my Department in association with the Department of Justice and Equality and the Office of the Attorney General, as legal advice indicates that lifting the Statute bar raises very complex issues that require broader consideration on a cross-departmental basis.
I have been informed by the Department of Justice and Equality that the current limitations of actions regime is the subject of a report and recommendations published by the Law Reform Commission in December, 2011 which considered the existing framework to be unnecessarily complex and in need of reform and simplification.
Current Practice Developments
Ireland is now one of the safest places in which to give birth to a baby. We have one of the lowest maternal mortality rates and perinatal mortality rates in the world. Ireland is now also one of the safest places to have a Caesarian section and we should be proud of the fact that we are recognised internationally as leaders in the field of obstetrics.
Recent legislation requires doctors to maintain and update their competence. These new requirements for doctors to maintain their professional competence are a significant step towards providing assurance that medical practitioners are appropriately qualified and competent to practise safely.
The National Clinical Effectiveness Committee last year published a framework for national endorsement of clinical guidelines and audit. The implementation of these national clinical guidelines is intended to improve health outcomes for patients, reduce variation in practice, improve the quality of clinical decisions, influence health service policy and inform service users and the public about the service they should be receiving.
These and many other developments are ensuring that the health system is moving to fulfil the vision of the Commission on Patient Safety and Quality Assurance, that is ‘Knowledgeable patients receiving safe and effective care from skilled professionals in appropriate environments with assessed outcomes.’
The new clinical programmes being developed and implemented in the HSE are one of the most important developments in this regard. These are currently led in the HSE by the Directorate of Clinical Strategy and Programmes which was established to improve and standardise patient care throughout the Health Service Executive (HSE) by bringing together clinical disciplines and enabling them to share innovative solutions to deliver greater benefits to every user of HSE services.
The clinical programmes are a multidisciplinary initiative between the HSE and the various faculties and generally include patient representatives. Each programme, including the Obstetrics and Gynaecology Clinical programme, is led by a senior clinician.
The aim of the Obstetrics and Gynaecology programme is to improve healthcare choices for women. Its initial work aims to:
- Implement key guidelines
- Establish local programme implementation groups to facilitate change
- Develop national models of maternity care
- Develop a standard approach to capturing and reporting audit and performance metrics
- Develop solutions and guidelines to reduce number of multiple pregnancies requiring neo natal intensive care
- Develop workforce planning & training models and strategy
- Investigate the numbers of women attending for antenatal care in early pregnancy
More generally there has been considerable progress in the options of maternity care available to expectant mothers in Ireland. They now have a number of choices they can make in respect of the obstetric care which they choose. Women may opt for a combined care package with their GP and the hospital, under The Maternity and Infant Care Scheme, which provides a number of free GP and maternity hospital visits to all eligible expectant mothers. There are also a number of midwifery led units nationally which offer the opportunity to expectant mothers to give birth in a uniquely designed birth room cared for by a team of experienced midwives. These units are located close to hospitals should an emergency arise that requires specialist intervention.
In February this year, I launched an important new patient safety initiative – the first National Clinical Guideline – the National Early Warning Score for Ireland (NEWS). The Early Warning Scores for obstetric patients have different points for escalation of care. The Irish Maternity Early Warning Scores System (IMEWS) was developed by the Obstetrics and Gynaecology Clinical Programme, HSE. The IMEWS was issued to maternity units in early April and is in the process of being implemented.
In addition, the HSE has established a national group to oversee the implementation of the national recommendations arising from the Investigation Team’s draft report into the death of Ms Savita Halappanavar.
While these developments can bring further improvements to maternity services in the future I am committed to addressing the issues that have arisen from past practice in relation to symphysiotomy. The Government is also committed to dealing with this issue, with all the sensitivity which is undoubtedly required, to do whatever is necessary to bring this issue to conclusion in so far as is possible for those affected by it. I have outlined the supports that have been provided to the women affected and the progress in finalising the research report.
I hope to bring finality to this issue as soon as possible and I firmly believe that the women who have had this procedure deserve nothing less.
Government is not persuaded that lifting the bar on the Statute of Limitations will resolve the problems facing the women who wish to bring their cases before the courts. The statute is in itself a constitutionally permissible limitation on the right to litigate and is possibly of constitutional challenge on the grounds that it unfairly prejudiced defendants and, or, was discriminatory between classes of defendants or classes of plaintiffs could not be ruled out.
Women may be encouraged to bring actions which may, for various reasons, ultimately have little prospect of success while at the same time generating high litigation costs for both plaintiffs and defendants.
However, to signal my intent to do whatever is possible to bring closure for these women I will support Deputy Ó Caoláin’s Bill. In addition, when I am in receipt of the facts that will presented in the Independent Research Report, which will of course include details of the consultation process with the women who underwent this procedure and any recommendations in this matter, I will brief government again on the matter, so that we may decide on further action required.