Children's Health Ireland: Statements

I welcome the opportunity to address the House on the independent Report on Children's Health Ireland Inquiry into Spina Bifida and Complex Scoliosis Scoping Exercise by Mr. Remy Farrell, SC. More importantly, I acknowledge the group of people who are here today in the Gallery, who have advocated for some time about complex scoliosis and spina bifida. In that context, I want to first put this conversation in the context of the lived experiences of patients and families who have been in Children's Health Ireland, CHI, in many different contexts and who have not had the care they deserved. For many children living with spina bifida, scoliosis or hip dysplasia more recently, and for the parents and families who care for them, everyday life involves significant challenges, uncertainty and worry. Mr. Farrell attempts to captures the real pain and frustration parents have felt for a very long time. I want to acknowledge that here today. I also want to acknowledge that for so many people I am very aware that any process that this House or the Government progresses will not alleviate pain and will not alleviate the past. What the Government and the Oireachtas are attempting to do is to bring together a structure that enables the investigation of the systems that enabled any of those extremely difficult outcomes that many parents, families and individuals have had to face. As a consequence, I appointed Mr. Remy Farrell as the independent facilitator for a scoping exercise in order to examine how we might progress to a statutory inquiry. I recall from meetings with advocates on complex scoliosis that they had two requests, the first of which was to bring CHI into the HSE. Legislation is being progressed with a view to that being completed by the end of 2027. The second request was to have an inquiry into the events that had led to extreme difficulties for their children. Mr. Farrell was appointed to scope the content of potential terms of reference for a statutory inquiry, in consultation with stakeholders. The process was designed to ensure that when an inquiry is established, which has been our intention, it has structures and parameters that reflect the needs of children and families, and that they are grounded in evidence, are timely and efficient and avoid duplication with existing statutory or clinical processes. Following his appointment in March, the facilitator initially wrote to stakeholders to introduce himself and to invite them to meet with him. The facilitator had various engagements with patient advocate groups, families and a number of clinicians, CHI and HSE management and the Department of Health. His engagement included both written correspondence and meetings. At the beginning of June, Mr. Farrell wrote to stakeholders inviting them to make submissions or observations in relation to the various issues and set out his initial thoughts on any proposed inquiry. He again wrote to stakeholders, including all advocacy groups, on 7 July regarding an extension of time, which he requested to enable him to have further engagement. I granted this extension to him in order to give him the opportunity to continue engaging and re-engaging with them. That is in part because there were some groups that chose not to engage at that stage, and because there were other groups and individuals who came to him at that stage. For both of those reasons, he asked for additional time. I acknowledge the bravery of those who chose to talk about their difficult lived experiences. I also respect and acknowledge that not everybody did. Everybody's participation in different ways added to his understanding of the essential human perspective of the varied and very different issues. I hope he has acknowledged that in his report in a way that reflects people's participation in it. Mr. Farrell submitted his final report to me on 9 September. I am grateful to him for the professional way in which he has conducted the scoping exercise. His work brought structure and clarity to a broad set of issues and concerns which required considerable sensitivity. As Members of the House will be aware, Mr. Farrell has recommended a commission of investigation covering four defined modules on waiting lists, spinal surgery, hip dysplasia and the important group of children who were not transferred to Temple Street post 2008. Mr. Farrell has recommended a commission of investigation over the other statutory model, a tribunal of inquiry, based on his view that a commission can deliver the same core statutory powers as a tribunal while being better suited to the specific subject matter of the inquiry, namely the medical treatment of children. A commission can compel witnesses to attend in the same way and compel the production of documents and a final report will be published. Crucially, a commission also enables a measure of public hearing. It is important that there is an opportunity for public hearing - the difference being that a commission also enables a private element as well, whereas the default in a tribunal model is necessarily public. In relation to the module on waiting lists, Mr. Farrell recommends two submodules. The first is a personal-family statement submodule and the second is a submodule in relation to the response of CHI management to waiting list issues. In the distinct personal-family statement submodule recommended by Mr. Farrell, parents and children would be asked and invited to give testimony in relation to their experiences regarding the impact delays and management of waiting lists had on them. It should not be confined to any specific hospital but to CHI generally. Insofar as the module relating to waiting lists is concerned, Mr. Farrell makes clear that he includes the National Orthopaedic Hospital at Cappagh. His recommendation is that this module be conducted on a non-adversarial basis. This a module that has the opportunity to be in private, public or by written documentation, essentially at the discretion of the individuals involved, enabling an important measure of choice. Regarding the second module, on spinal surgery, his recommendation is that a commission should inquire into the response by CHI to delays and management of waiting lists for spinal surgery or assessment across CHI. It should also inquire into how funds allocated on foot of the scoliosis and spina bifida action plan 2022-23 were spent. It should also inquire into the circumstances surrounding five urology clinics and whether they complied with applicable NTPF rules. While Mr. Farrell does not recommend that the issues covered by the ongoing Nayagam review and by the completed HIQA report should be inquired into, a discrete issue regarding the latter does arise. Mr. Farrell recommends that a commission should inquire into whether the management of CHI was aware of the use or intended use of non-CE marked springs in surgeries undertaken by consultant A between 2020 and 2022. In relation to the module on hip dysplasia, Mr. Farrell recommends that a commission should inquire into the surgical threshold for developmental dysplasia of the hip, DDH, that was in operation at Temple Street and Cappagh. This module should consider whether the threshold was appropriate and justified, the reasons for any deviations from the threshold and the response and awareness of management to this. He recommends that this module should await the outcomes of the external expert panel review before it commences its work. For DDH, the HSE has established a separate process in relation to retrospective reviews to determine the indications for surgery. This is known as the external expert panel review, as I said. The independent expert panel will review patient files to determine, insofar as it can, the appropriateness of the original decision to operate in individual cases based on the appropriate radiological indices and clinical history informing that decision. Lastly, he recommends that a commission should inquire into the care received by the group of patients who were not transferred from Crumlin to Temple Street following a HSE decision in 2008. He recommends that a commission should consider the experiences of patients and their families within this group during that period and, crucially, the CHI management of same. It is important to be clear on what a statutory inquiry can and cannot do, and how it fits into the overall legal architecture of places within which we can get redress and remedy. As Members are aware and as Mr. Farrell says in his report, what a statutory inquiry can achieve is primarily the identification of what has occurred in the past. Insofar as recommendations flow from such conclusions, they tend to be at best broad recommendations. A statutory inquiry is not the appropriate forum in which to decide how future children's health should be delivered, managed or resourced. I suggest that is for this House to do. Mr. Farrell makes clear that those matters remain for the relevant executive and legislative bodies to decide. While it might help to improve the understanding of what went wrong in the past, a statutory inquiry cannot itself deliver the operational, clinical or policy changes needed. It is important to make sure that is understood. It is not possible within the legislation or the model of any type of statutory inquiry. A statutory inquiry is not a clinical process. Mr. Farrell suggests that we do not duplicate or replicate those pieces of clinical examination that are under way and which are appropriate for clinicians, but rather that those findings would inform the work of a commission which would be led by a person who is not a clinician but a senior judge or retired senior judge. Mr. Farrell does not recommend a diagnosis-based inquiry into every aspect of scoliosis care. Instead, he has defined modules by the different issues. A statutory inquiry’s primary role is to establish and explain what happened in the past. It can investigate events, identify failings and make generally broad recommendations. Crucially, it can improve public understanding and provide a moment within which the broader public understands that something happened that should not have happened and attempt to acknowledge that in statutory form, independent of this House and the Government. However, it is not designed to solve complex service delivery problems or implement reforms. A statutory inquiry is not a vehicle within which we can identify or determine what happened in specific individual cases. There are important separate processes where individual cases can be appropriately examined such as a systems analysis review or, very sadly, in some cases, a coroner’s inquest. Those are the existing legal proceedings for examining individual cases. It is not the function of a statutory inquiry as such. Further, in his report Mr. Farrell suggests it may also be necessary for the inquiry to consider a sampling approach in order to enable a commission to take a view as to what may or may not have occurred in a broad manner. The Commissions of Investigation Act 2004 is sufficiently flexible to permit different methodologies to be applied in the context of any such statutory inquiry including sampling. He gives that opportunity of flexibility for the statutory inquiry. I am aware that there are calls for a tribunal of inquiry as opposed to a commission of investigation. As I outlined earlier, Mr. Farrell recommends a commission of investigation over a tribunal based on the view that a commission can deliver the same core statutory powers as a tribunal. However, he is also of the view that as these issues deal with the personal and medical information of children who have specific legal protections and given the relatively finite number of children involved, there is a significant risk that children may be identifiable even where anonymised. A commission on the other hand by default is largely conducted in private with the opportunity to go public. In his view, that alleviates the concerns compared with a tribunal which by default is conducted in public and allows for the cross-examination of all witnesses. His concern is that as a consequence of that, a commission may encourage broader participation because there are those who do not wish to be questioned in public, those who may be more willing to share personal experiences and those who may be more willing to discuss concerns, mistakes or experiences more candidly and provide sensitive evidence. For this reason, he favours the commission model over a tribunal model as it enables all of that flexibility. There is a view among some parents that it should be held entirely in private and among other parents that it should be held entirely in public. Mr. Farrell outlines in his report that although the default position is that evidence received by a commission is received in private, it is by no means an inflexible rule. The Act allows for a witness to request from the commission that all or part of their evidence be heard in public. I am aware also that there is a response to Mr. Farrell’s report that the commission is too narrow. Mr. Farrell emphasises the importance of having a focused and clearly defined inquiry. That comes from our experience of previous statutory inquires. He notes in particular that a commission operating within precise terms of reference is more likely to deliver findings within a defined or reasonable timeframe. The legislation requires that the terms of reference specify the events, activities, circumstances, systems, practices or procedures to be investigated. The legislation also requires that it should identify relevant time periods, locations, organisations or individuals. That legislation is based on our collective experience of how we managed statutory inquires in the past. In his work, Mr. Farrell ensured each issue was addressed on its own merits to determine whether further examination was warranted. That involved identifying issues, some of which had been adequately addressed, areas where unanswered questions remain and matters that benefit from further examination through a statutory inquiry. It is not in our collective interest that we do not get an outcome from this inquiry. By that I mean it is important that we set parameters. When we had a debate on this in the past, Members were clear they did not want this to go on in a way - I do not want to say an "interminable" way - that did not get an outcome and was not defined. We have had, as Members know, tribunals of inquiry that lasted up to 12 years in the recent past. That is not in anybody’s interest. For the module on waiting lists, Mr. Farrell suggests a timeframe from 1 January 2019 to 31 December 2025. For the module on hip dysplasia, he recommends a timeframe from 1 January 2019 to 31 March 2025. As I have mentioned, Mr. Farrell notes that inquiries work best when they have a defined scope and time. He suggests 2019 as the start date given that Children’s Health Ireland was, I believe, established in December 2018. This is a six-year period that deals with both the period before Covid-19 affected services, during Covid-19 and after Covid-19, allowing for an assessment of the pandemic’s impact on waiting lists and focusing on events related to CHI as an organisation. Crucially, it also acknowledges that disruptions to services and surgeries not happening was not as a consequence of Covid-19. That is why it is so important to have a period in advance of that as well. Waiting lists did exist. Waiting list challenges very definitely existed before 2019, but Mr. Farrell recommends that period as an effort to put parameters on the commission. The Government has accepted the report’s recommendations and we want to begin drafting terms of reference for a proposed commission of investigation. Officials in my Department will work in close consultation with the Office of the Attorney General in drafting the terms of reference. It is important to me that stakeholders are involved in this process and there will be an important call for input from advocacy groups on the terms of reference. As we have always said, the terms of reference are ultimately a matter for the Government to approve. Similarly, at the same time we have had a process of a commission of investigation into the acts of the paedophile Michael Shine. By way of corollary, my officials are in contact with Dignity4Patients, a group representing victims, in relation to their view on supports for participants ensuring that the commission will be trauma led and trauma informed. We want to replicate that process here. Learnings from that process will enable us to ensure we do everything we can to ensure the establishment of this commission is inclusive, timely and efficient. I know there are concerns that this will take a very long time to set up. Again, as a comparison, Members may be aware that following Lorcan Staines SC’s scoping exercise report, the Government agreed to the initiation of the drafting of terms of reference for that proposed commission of investigation in July. Officials in my Department have been working in the period since and very significant progress has been made in that regard. It is important that every element of this process happen in an expeditious way in order to allow people to have the opportunity to contribute their experience to the commission. There are a number of different ongoing processes I would like to reference, which are important because they will inform the proposed investigation. Overall, the aforementioned external expert panel review is progressing reasonably well. The panel has completed the testing and validation process and it commenced its formal review of cases in August. A letter to all the stakeholders will issue shortly by way of update, and that work will be completed in 2027. It is really important that this work conclude to be able to inform any next steps and, crucially, a commission. Separately, we have the ongoing Nayagam review. The chief clinical officer of the HSE commissioned this UK expert to lead an external review of the paediatric orthopaedic surgical service at Temple Street. The review is in two parts. Phase 1 is a risk assessment of the practice of an individual consultant. Phase 2 is a review of the paediatric orthopaedic surgery service at CHI and other specified Dublin hospitals, to include a review of their governance, systems, processes and capacity. That is a much more clinical focus being done by a clinician. However, by way of update, phase 1 has been completed. Mr. Nayagam recommended a recall for clinical review of 62 of the 91 cases examined by him. All of those have been contacted, appointments are being progressed and a number of young people and adults have had their clinical follow-up. On foot of phase 1, the HSE decided to carry out a wider look-back at the individual consultant’s practice. That will include a review of the patients on whom the individual consultant performed surgeries between 2016 and 2023 in the following domains: all spinal cases, surgical dislocations of the hip, and limb reconstruction cases. Intensive work is under way to establish the number of patients who will be involved in that look-back process. The purpose of that is to detect harm that may have occurred and to ensure a patient is on the correct pathway. That itself may point towards further inquiry. Phase 2 of Mr. Nayagam’s review is under way and is expected to be completed mid-2027. That phase 2 review is important from a broader clinical and system patient safety perspective to assure on future service provision, especially in the context of the move to the new national children’s hospital. As I outlined earlier, Mr. Farrell says in his report that a statutory inquiry cannot itself deliver the operational, clinical or policy changes needed. That responsibility lies with me and with us. The Government has recognised and continues to recognise and prioritise families accessing paediatric spinal services, and there has been a significant additional investment to help reduce waiting lists. We are seeing this year in particular and last year that it is beginning to make a difference. The investment and the associated initiatives are focused on increasing capacity across the care pathways and building a much more sustainable service that can respond to the needs of children and their families. Several initiatives are under way to improve services. We have a ring-fenced theatre and additional outpatient clinics, including on Saturdays, and the outpatient waiting time has gone from about nine months to less than four months. That is important. We have national and international outsourcing pathways to maximise capacity where people choose to use that. We have written and written again to families to offer that. Very few families have taken it up but the offer is an open one if people wish to travel abroad. Further improvements are under way, including the recruitment of additional orthopaedic surgeons, which enables spinal surgeons to devote more capacity to spinal surgery. Indeed, a surgeon was appointed last August, and others who have been appointed are now doing specialist fellowships and will return to the service. Meanwhile, there is locum cover for that. What we are observing this year in particular is an increase in the amount of really complex spinal work, often done by two surgeons instead of one. That has meant the numbers have not been as high but much more complex work is being done. That is the reason for it. We are having two spinal surgeons work together to ensure the complex work is being done rather than being allowed to drift, which is what has happened in the past. We also have a key worker or patient navigator in post to make sure every family has a named point of contact to support them throughout their child’s care, something that did not happen appropriately in the past. There has been a dedicated paediatric spinal surgery management unit in CHI since 2024, to drive continuous improvement across the service and be responsible for managing the delivery of spinal surgery. It is led by a consultant orthopaedic surgeon, is supported by a wider multidisciplinary team and ensures patients are prioritised correctly for surgery. That does not count, however, unless the surgeons are there to do the work and unless the theatre is available, and I do see improvements this year. One hundred per cent of outpatients are now waiting less than 12 months for a first appointment, which is entirely appropriate. A central referral process has commenced to ensure that patients are seen in the right location, by the right consultant, as quickly as possible. Since international outsourcing started in 2024, 19 patients who were considered suitable for surgery have had it completed abroad. For those 19 patients, 25 procedures were completed. As I have said, we have written again, both in March and August 2026, to patients on the active waiting lists to offer them the opportunity to travel abroad, and that is an open offer. The recruitment for a spinal registry team is now complete. As I said, however, there are people on fellowships and it is about making sure they are here in the longer term, but we are seeing the impact of the additional surgeons. The CHI improvement steering group is co-ordinating oversight of the range of matters of focus in CHI and it is making a difference. The weighted average wait time for outpatients has fallen to 3.8 months. The weighted average wait time for inpatient procedures is also down in the last 12 months. At my direction, we will continue to have that focus to make sure children are getting the outpatient services, the care and the surgeries they need. I also want to mention the very necessary work to implement the integration of Children's Heath Ireland into the Health Service Executive, a key ask of advocates. A general scheme of the Bill was approved by Cabinet on 14 July of this year. It has now been published. Pre-legislative scrutiny took place on 7 October. I thank the committee for that. We will progress that legislation expeditiously and I expect integration of those services to be complete in 2027. I recognise the real pain, the difficulty and the enormous trauma to so many people's lives as a consequence of a failure to get the correct surgery or to have the appropriate wraparound care for their children. It is truly enormous and I recognise that on behalf of the Government. Our effort to set up a commission to acknowledge and investigate the systems that enabled and led to that is one that is truly genuine. We genuinely wish to deliver something that can be the most inclusive, for those who wish to be public or private, and to draft terms of reference in a way that enables the best flexibility and inclusivity according to Mr. Farrell's report.

This inquiry is not being established because the system worked; it is being established because, over many years, children were failed. Children waited in pain. Children waited while their conditions worsened. Children waited so long that the treatment they ultimately needed became more difficult, more complex and, in some cases, inoperable. Children were removed from active waiting lists without their parents knowing. Children fell between services. Children with spina bifida became known as the "Crumlin orphans" because of the gaps in the specialist care they needed. Children had unauthorised springs implanted into their bodies. There have been serious concerns about hip dysplasia surgery and about the threshold at which children were operated on. There have been serious spinal surgery incidents. There have been failures of waiting list management, failures of governance, failures of clinical oversight, failures of accountability and failures of communication. Throughout all this, there has been a failure to listen to parents, and that is why we are here. History matters in this context. We cannot start talking about this scandal from 2019 because the failures did not begin in 2019. For many years before the establishment of Children's Health Ireland, parents were raising the alarm. Children were waiting extraordinary lengths of time for life-changing surgery. Parents watched their children worsen while they waited. Those parents campaigned. They protested. They spoke publicly. They came to this House. They forced this issue onto the political agenda. It was in that context that in 2017 Simon Harris, when he was Minister for Health, made the commitment that no child would wait longer than four months for scoliosis treatment by the end of that year. That promise was not made in a vacuum. It was made because there was already a crisis. It was made because children were already waiting for too long. It was made because parents were already telling the Government that their children were suffering. It was an acknowledgement by the State that allowing children with progressive spinal conditions to wait for years was unacceptable. That promise was broken. Children continued to wait beyond four months, and some children still do today. That is why I cannot accept 1 January 2019 as the starting point for this inquiry. It is an arbitrary cut-off when measured against the actual history of what happened to these children. If we start in 2019, how do we properly examine why the 2017 commitment had to be made? How do we examine everything that led up to it? How do we establish why it was not delivered? How do we examine what happened to children who were already waiting before CHI was even established? How do we establish whether the failures we subsequently saw within CHI were new failures or a continuation of problems and patterns that had existed for years? The Minister and the Government have said the chair of the inquiry can have discretion to look further back, but that is not good enough. This cannot be left to discretion. The terms of reference matter. The starting date written into these terms of reference matters. Those terms will define what the inquiry is required to examine. Parents should be able to read them and know that what happened to their children can and will be examined. They should not be told that maybe the 2017 commitment will be examined, maybe what happened before CHI was established will be examined and maybe what happened to their child will fall within the scope. There can be no ifs, buts or maybes. If these issues matter, and they do, they must be explicitly within the terms of reference. This is about rebuilding trust. You cannot ask parents who have spent years fighting the system to take another leap of faith and simply hope that the chair may look at something. The scoping process itself recognises that some of the issues involving the children described as the "Crumlin orphans" reach back well before 2019. At the meeting with the Minister for Health and the Tánaiste on 12 November 2025, advocacy groups specifically raised the need to go back as far as 2005. This needs to be resolved now. The Minister needs to put it in the terms of reference and give the inquiry the clear authority and obligation to go back far enough to establish all the facts. Unless we establish the full timeline, we cannot identify the patterns, and if we cannot identify the patterns, we cannot properly understand how children were failed. Children's Health Ireland is central to all this. CHI was established under legislation brought forward when Simon Harris was Minister for Health. It was supposed to bring children's hospital services together under a new structure. It was supposed to improve governance, integration, accountability and outcomes for children. Now CHI is being brought to an end, mired in controversy, as a separate entity and its functions are being reintegrated into the HSE. What an extraordinary journey children and parents had to go on for that to happen. An organisation established to improve the governance and management of children's healthcare is now being dismantled. That cannot be separated from the serious failures of management, governance and oversight that have emerged, nor can we ignore the Government's handling of all this. For years concerns were raised. Parents raised them. Advocates raised them. Clinicians raised them. We in Sinn Féin and others in opposition raised them. Reports were written. Warnings were given. Too often the Government put its head in the sand. We have had report after report, review after review, investigation after investigation. We have had the Ombudsman for Children raise serious concerns about scoliosis waiting lists. We have had the Dixon report and the issues involving children with spina bifida who became known as the "Crumlin orphans". We have had the Nayagam review into paediatric orthopaedic surgery, which is still not complete. We have had the HIQA investigation into implantable medical devices and the unauthorised springs at Temple Street. We have had concerns and reviews relating to developmental dysplasia of the hip. We have had audits and reviews of waiting list management, access to care and governance. We have had published reports and unpublished reports. Now we have the Farrell scoping process. It is a list as long as any of our arms. What is missing in all that is the Government listening to parents and real accountability. At some point all the pieces of this jigsaw have to be put together. That brings me to another fundamental concern. You cannot properly understand these failures simply by looking at structures, policies and waiting list systems; you have to examine what actually happened to individual children. The failure of a healthcare system is experienced by a person. A waiting list does not feel pain; a child does. If a child needed surgery and was left waiting while their spinal curvature worsened, examine that child's experience. If a child was removed from a waiting list without their parents knowing, examine what happened. If a child was left without the specialist care they needed, examine why. If questions subsequently arose about a procedure carried out on a child, examine it. If serious concerns were identified about a child's care and their parents were not told, establish why and how that happened. Individual cases are not a distraction from systemic failures; they are how we expose systemic failures. We need to ask what care a child needed, how long they waited, what decisions were made, who made them, what their parents were told and what happened when concerns were raised. If we do that across enough children, the patterns will be very clear. That is how you establish the truth. Parents have been trying to tell us this for years. They were the whistleblowers. They were screaming from the rooftops. They were saying the waiting lists did not tell the full story. They were asking why their children could not get appointments. They were challenging decisions. They were looking for second opinions. They were demanding answers. Their very strong view is that they were not listened to. In truth, they still feel they are not being listened to. The Government has to confront that reality. If those parents had been listened to properly and earlier, many of these crises and scandals could have been prevented. That is why it is so important that they are listened to now. That brings me to the meeting of 12 November 2025. Families and advocacy organisations came to that meeting in good faith. The Tánaiste was there and the Minister was there. The minutes record that the latter intended to bring forward a statutory public inquiry that would, in principle, be a tribunal of inquiry. They record agreement that a mediator would work on the terms of reference and, when the groups asked that the mediator be agreed by both sides, the minutes state, "This was agreed." They record discussion about an independent clinical expert not connected to CHI and potentially from outside the Irish healthcare system. The families and advocacy groups say that the facilitator was not agreed with them and that the independent clinical expert discussed at that meeting was not appointed. They say the further meaningful engagement they expected never happened. What is missing here is a requirement for transparent, public giving of evidence. Some parents may be able to give evidence publicly as part of a specific module. The concern is that CHI senior decision-makers and those whose actions are under scrutiny will not be required to account for themselves in the same public way. That is a real difficulty. If this inquiry is to rebuild trust, there can be no hiding places for anybody. It would be wrong if the evidence from those responsible for decisions, failures and oversight were examined only behind closed doors. Public accountability has to matter too. Before the terms of reference are finalised, the Minister needs to sit down again with parents and advocacy organisations to listen to them and to address their concerns. Trust is on the floor, and the only way the Minister can begin to rebuild it is by establishing an inquiry that is genuinely independent, genuinely comprehensive and genuinely fit for purpose and that for the first time puts families and children first.

I welcome the families who are in the Gallery today. None of you should have to be here. None of you should have had to campaign and advocate on these issues for so many years. I know how much heart, soul and effort you have put in to try to get the truth here. It should not have happened. You have campaigned for this crucially important inquiry and the Government now has to get it right. That is the key message. The scale of the failings in CHI is extraordinary. Children were left in excruciating pain as they waited for surgery and some have, sadly, passed away. We need to get this right for all of them. I share many of the concerns set out by Deputy Cullinane. I know other Opposition Members share similar concerns. The first of these concerns in the timeline. This cannot start in 2019. We know that it goes much further back. The work currently under way in relation to the unnecessary hip surgeries is looking back to 2010. That work is already under way. That was well before CHI was established. If we are covering that area in an expert review and all that goes with it, we should be doing the same with the inquiry. The 2014 Temple Street report found serious failures in spina bifida care. In 2017, we had that infamous promise when Deputy Simon Harris said on national radio that we were going to get this right and that no one would wait more than four months. In that interview, he also said there was a direct correlation between the recession and waiting times. The then Minister for Health told us on national radio that there was a clear link between waiting times and the recession. The Government is now proposing that this whole period not be looked at. That is a mistake. We cannot write that period out of the record of the inquiry. The Minister should go much further back. I know others share that concern. One of the big things that was discussed was the difference between a public inquiry and an inquiry behind closed doors. I will read some extracts from Mr. Farrell's report because he puts it quite well. He says: As matters presently stand, the law provides for two similar but distinct types of statutory inquiry, namely a Tribunal of Inquiry and a Commission of Investigation – as I indicate above for simplicity I refer to these as a Tribunal and Commission respectively. For the sake of completeness I should also observe that it would be open to the Oireachtas to create a bespoke model for the purpose of a statutory inquiry into the matters under consideration here. He goes on to say, "A further key difference between Tribunals and Commissions is that there is a default assumption that a Commission will conduct its investigation in private." Under point 295, he says "As one might expect, clinicians are generally in favour of a commission model, whereas some of the patient groups advocate strongly for a tribunal." This sets out the clear difference and the clear demand I have heard from families and advocates. Many of them want as much of this as possible to be done in public. They want it out there. They want people to be able to hear and see the evidence. Sunlight is a good disinfectant. We know there are concerns about confidentiality but there are ways to address those. There are ways to do parts in private. However, the default should be for this to be in public. There are ways in which that can be achieved. I will also talk about the need for mediation here because there clearly is an impasse. On 12 November 2025, families met with the Tánaiste and with the Minister for Health. I have seen the minutes of that meeting, as recorded by the Department. Those minutes record the intention to establish a statutory public inquiry, in principle, a tribunal of inquiry. Crucially, the minutes explicitly record agreement that a mediator would be agreed by both sides. Raymond Bradley SC requested that a mediator be mutually agreed and the minutes state that this proposal was agreed to. The Tánaiste welcomed this development but that commitment was never honoured. The process proceeded without that agreed joint approach. The advocacy groups have written to both the Taoiseach and the Tánaiste. They want to propose a constructive way forward. The appointment of a mutually agreed mediator would help to resolve the impasse between the Government and affected families and to restore confidence in the process. I urge the Minister to heed that call and to appoint that mediator. It is not too late. As I said when I met the Minister privately, I also think this inquiry needs to be independent of the Department of Health. It would be better situated in the Department of the Taoiseach in order to create that separation. That is very important. It is important that we look at the scope here. We must not just look at how waiting lists were managed. We need to look at outcomes for children and the lifelong consequences for them, including loss of kidney function and fertility. We need to look at what happened to the children who do not neatly fit into the four modules proposed, particularly those children who have sadly passed away. The families I have spoken to feel like an afterthought. They feel they have been treated poorly, strung along and fed excuses while the system closed ranks before them. Things were meant to change but they feel let down again. It is not too late to change this approach.

I apologise. I know Deputy Cummins is also coming in on this. It is crucially important that we get this right. As I have said, the timeline is crucially important. We must look further back. We must get the scope of the inquiry right and hold as much of it as possible in public. A large number of families really want it to have that independence. The Minister should appoint that mediator and engage with the groups and families that are directly affected. There is an impasse here. There is a really strong difference of opinion between many of the families who are directly affected and the Government. The families and children affected deserve the best inquiry possible. As I have said constantly, the Minister has just this one golden chance to get it right. If she does, she will have the full support of the Social Democrats and other colleagues in the Opposition. I urge the Minister to listen to these calls, to our feedback and to what is being said. Let us engage constructively on this. Let us ensure we have an inquiry that is fit for purpose.

When I come to talk about this issue, I always remember that, at the end of the day, these are children who really want to play, to be with their family and friends, and to do the things that every child wants to do. Before I start, I thank my colleague, Deputy Rice, who has done so much on this issue. As he said, we want to work with the Minister to make sure that this is the best inquiry it can be for those children and their families. One of the things that has struck me when this issue has been talked about is that families have to talk about their personal details. This is not the only medical issue in respect of which this happens but it is incredibly difficult for families who have a child who needs a surgery to make things right but who is not getting it. As a parent, I cannot imagine how frustrating and heartbreaking that must be. It affects the whole family, including any siblings. We have to get this right. If we do not, it will end up in a State apology. Before I came in, I was looking at some numbers. In September 2026, there were 86 patients on the active spinal surgery waiting list. There were 357 spinal surgeries performed from January to September. The figure for new active and planned procedures from January to September 2026 was 272. There were 31 planned procedures for 25 patients. These are humans at the end of the day. We have to get this right. There are waiting lists for everything. There are waiting lists not just for medical procedures but for the other things that come after the surgery. Many parents contact me about children who have additional needs. There are waiting lists for children's disability network teams, primary care, physiotherapy, occupational therapy and the dentist. It is every single thing. I was very impressed with how the Minister spoke earlier about endometriosis and her determination to get that right. I hope she is as determined to get this right because there are many challenges in our healthcare system at the moment. I plead with the Minister to do the best thing for those families and to listen to them. As Deputy Rice said, there is an impasse. The only way to get through impasses is to speak and to figure out how to do things together. We must remember that, at the core of all of this, is a child who just wants to be a child, to play and to live their best life. I implore the Minister to do the best she can.

This debate is particularly important because it is about the health and safety of the children of our nation, particularly our most vulnerable children. The test for the State has to be how we treat our children. I find the Minister to be incredibly empathetic. She puts the interests of the patient first in all of her approach to dealing with this issue. Based on her remarks, she is putting the children, the patients, and their families first. We have to acknowledge, however, that the public's confidence in children's healthcare has been strongly challenged in recent years. We will talk about the Remy Farrell report and the commission of investigation that is going to happen, but given what has happened, our overall challenge in here at the end of that process, apart from justice being provided for those who have been impacted, is rebuilding trust in children's healthcare in the State and ensuring it is done in a transparent way. I welcome the fact the Government has accepted Remy Farrell's recommendation around a commission of investigation being established into spinal and orthopaedic care with Children's Health Ireland, and it is critical, as the Minister has outlined, that families, including the children where appropriate, clinicians, patient advocates, CHI, the HSE, the Department and everybody who is involved in any way in this process is engaged within this. It needs to be done in as transparent a way as possible. It is critical that, at the end of this and apart from getting some of the answers, we have to be certain that we are able to build trust. The Minister spoke about how it would look at waiting lists between 2019 and 2025. Consideration may need to be given to some of those children impacted before 2019, if it is relevant to some of the discussion, and there should be an openness in that regard. The terms of reference are there and are clear, but if they need to be broadened as time moves on, I ask the Minister to consider that. As others have said, this is about more than individual incidents. This is going to be looking at issues around governance, culture, systems and accountability, which unfortunately are some of the challenges that we regularly see within our healthcare system. Regarding the questions that families have been asking, for us as legislators and for society generally, we want to know by the end of it whether the concerns were listened to. Were the warning signs identified sufficiently early? Did the information pass along to the relevant decision makers? Was action taken quickly enough when the problems emerged? These questions need to be answered clearly when it comes out, not only for the patients and their families, but also for society more broadly. It is not just enough to simply established what has happened. We need to look at who is responsible now for addressing some of those challenges to make sure that they will not happen again and similar families are not put into a similar position. I am particularly concerned about how some patients' records were handled, and I hope this will be examined in detail. The Data Protection Commission will be involved in this, but we are talking about children's medical information. It should be treated safely and securely at all times. I hope that some of the data protection issues will be addressed in great detail. Our other challenge when we talk about children's health in future is to learn lessons from this. We are moving towards finally seeing the opening of the national children's hospital, NCH. We have to acknowledge the enormous commitment of front-line healthcare staff and what all of our doctors, nurses and others are doing, but good people need good systems. As part of our rebuilding of trust, I do not want see that, once we have restored an element of trust as a result of this investigation, the same systems and so on are replicated when the NCH gets up and running. We need to make sure that when the NCH opens, it starts off by saying that it has learned lessons from the past and the kinds of risk that were identified have been solved. In her response, I want the Minister to talk about how the NCH is going to operate. A lot of the discussion within this Chamber has rightly been about the costs and overruns, and I know that the Minister is seeking to address them. Like her, I support the fact that we should have a world-class hospital, but how will we know that we have learned from experience and that the systems in place when the hospital finally opens do not replicate the problems that we have seen in CHI previously? If we simply replicate them, we are going to continue them. Part of the problem is that, too often, public procurement is judged by the successful award of a contract. A Minister gets to announce that we have finally awarded the contract for the building of something. In terms of our public procurement processes, and particularly in healthcare, we need to look at what we have learned from previous experiences. It cannot just be awarded to the economically advantageous tender. In terms of us rebuilding trust in the public healthcare system, I hope that the Minister will be able to outline some of the details of this. There are obviously the issues around the commission of investigation, and I know that the Minister is willing to listen to the concerns that are here, but we need to have systems in place that ensure that these sorts of thing do not happen again. They have happened too often, and when it comes to children in particular, they cause great distress and undermine public confidence in our child healthcare system. We need transparency in order to build that trust. We need clear answers to emerge out of this. We need a process of engagement involving the Department, HSE and those impacted. We also need to ensure that, at the end of this process and when we finally get to the opening of the national children's hospital, the systems are in place and what we saw happening before will never happen again.

I want to address what I believe is one of the most serious omissions in the proposed inquiry process. Module 2 explains whether CHI management knew about the use of non-CE marked springs in spinal surgeries at Temple Street. That is an important question, but where is the examination of what happened to the children? Where is the examination of infections, complications, revision surgeries, unplanned returns to theatre and the long-term consequences for children and young adults? Where is the examination of whether poor outcomes were identified, investigated and acted upon? Instead, the proposed approach considerably relies on the Nayagam review, which concerns one surgeon's practice as CHI Temple Street and Cappagh. Phase 1 has been completed, but parents have not been given access to the full report, and phase 2 remains ongoing. What about CHI at Crumlin, the designated specialist centre for pediatric scoliosis care? Why is there no comprehensive examination of the surgical outcomes at that hospital? This is supposed to be an inquiry into children's spinal and spina bifida care. The inquiry cannot limit itself to examining what hospital management knew about the implantation of non-medical springs in children while failing to investigate the clinical outcomes, complications and long-term consequences of spinal surgery for the children. Families are not asking for an inquiry into paperwork or management knowledge alone. They are asking what happened to their children, whether harm could have been prevented and who was responsible. Will the Minister expand module 2 to place children's clinical outcomes, experiences and long-term well-being at the centre of this inquiry? It is clear that the Minister and her colleagues are hiding from public inquiry because they know that they have failed these children and their families. The appointment of an independent mediator was agreed by all parties on 12 November last year. The Tánaiste, Simon Harris, welcomed this development. A year on, there is still no mediator and the Chief Medical Officer, CMO, has still not appointed an outside clinician as requested by the Minister. This Government should not be putting up barriers to truth and accountability. I will close with the words of a parent in my constituency: As parents of a child that had a non-registered medical device implanted without our consent or knowledge, we feel that we have been left with more questions than answers. To narrow down the TORs to one question regarding this particular scandal is completely unacceptable. Our experience since the scandal broke three years ago has shown that a public inquiry will be the only way to get answers to the continued secrecy around the mismanagement of CHI that has left our child with physical and emotional scars for life. The only way to restore any trust going forward is to hold a public inquiry. This should not have been allowed to happen to our child.

I welcome all of the families in the Public Gallery. Today should have been a day of celebration because, after many years of fighting for justice for their children and the right care for their children, there would finally have been an inquiry into the wrongs that happened in CHI. Instead, we are here arguing with the Minister about this inquiry and how it is flawed from the get-go. One of the biggest sins in politics is to give people false expectations. Not only is it dishonest, but it is also hugely corrosive of the trust in people making decisions. The parents of children with scoliosis and complex spinal needs have had their trust in the institutions of the State dented time and again through repeated failures and the lack of timely care for their children in CHI. After the disastrous promises made by Simon Harris back in 2017, I would have thought that no Minister would walk into a meeting and give such clear commitments only to turn on them a short time afterwards. We have to understand why people want a public inquiry. For years, they have been gaslit and told they were hysterical and finding fault where none existed. They were told that they were in the wrong when that was not true. As Deputy Rice said, and it is a phrase I often use, they want the disinfectant of sunlight on the culture and management of CHI, but they are not clear about whether they will get this. The understanding of those in the room on 25 November was that there were clear commitments made to the public inquiry and that there would be a collaborative approach to the terms of reference. The argument can be made that the Minister has to devolve responsibility to a senior counsel to understand what the most appropriate forum is, but the Minister is an experienced politician. So is the Tánaiste, Deputy Harris. The Minister knew exactly what was being committed to in that room. The reality is that is not what the families are getting now. The reality is also that we have a once-in-a-generation opportunity to uncover systemic cultural and governance failures in CHI. We have to get it right. The Minister talked about wanting it to be inclusive and comprehensive, and I agree. As this stands, though, I do not believe it is. On the issue of public versus private, I have had a certain sympathy with the notion of it being in private because these are children, some of whom will grow up to be adults and some who will not make it. The reality is we cannot underestimate the depth of frustration and distrust that so many of these families have in the systems of the State. They do not want the decisions about the sampling to be made in private. They do not trust the process for who will be selected. They want to know who will be before the inquiry to make sure that everybody who should be will be. Unless it is in public, they will not have confidence in this very large undertaking by the State in terms of a commission of investigation. It is a small number of children in the general scheme of things. I do not see any reason that all of those children's cases could be not gone through. Some of them will have been a success - in fact, many of them will have been - but there are lots of others who have been failed. We cannot take the risk that some of those will be excluded. The other critical issue that has already been mentioned is the 2019 cut-off. To be very frank, the Remy Farrell report offers no convincing reason to exclude children treated at CHI before 2019 other than for administrative reasons. That is simply not good enough. We know that there were reports going back to 2014 in Temple Street. We know that many children's issues do not specifically relate to just before or after their surgeries. Those issues go back a long time. There are families here today whose children have finally got surgery and, hopefully, those children will go on to live fulfilling lives. There are other families where it is too late for their children and the time is now ticking for those children as to how long they live. There are other families whose children have died. In the Public Gallery today, we have William and Anne-Marie Clooney from County Laois who lost their son, Cathal, five years ago just six weeks after scoliosis surgery. He was 15 years of age. He effectively bled out after a series of complications after his surgery. To be honest, I am haunted by what his dad has said to me over the last number of weeks. He said that no one knew how anything happened. To this day, they still do not have answers. There were a litany of errors and issues in Cathal's care. He was never properly diagnosed. It was only after his death that they finally realised what the condition was. In his 15 years going to CHI, never once was there a blood test for his type of condition. He was visually inspected at the age of about one week old and doctors worked off that diagnosis for his 15 years of care. The family were told varying things about Cathal's condition after his death. They were originally told that he had had Covid, then he had not had it, and then they were told again that he had had it. The family did not know that he had had sepsis. Most crucially, when the part-post mortem was undertaken, there were things written in it that the family had never been made aware of before, for example, he had known severe Ehlers-Danlos syndrome, EDS, and a respiratory condition. The family knew that he had EDS but they did not know it was severe and they certainly never believed he had a respiratory condition. The family was effectively told that he would not have had long to live anyway. That is a reflection of the culture and manner in which families were treated. When Cathal's family requested an inquest, they were originally told they would probably get one. They were then told "No", and it was only because they initiated legal proceedings that they were finally granted one. It is also important to say that a HSE official told them that if they ever spoke out, they would be accused of slander. We have to understand the culture of oppression that these families have been treated with and the critical importance of having their stories told in public. The reality is an inquest will not give all of the answers to that family. It will deal with his death but it will not deal with the lack of diagnosis going back 15 years when that child was born and in the days after his birth. There are families who believe they will not be included in this process. It is a once-in-a-generation opportunity to get this right. If we are doing it, we might as well do it right. It is going to take years and I do not think any of us should fool ourselves into thinking it will completed in the next two or three years. If it will take years, let us make sure that we give confidence to the families that they will be included. The Nayagam review commenced three and a half years ago. Phase 1 has been completed and we are waiting a very long time for phase 2. I know the Minister has said it will be 2027 when we get that report, and that should provide some answers as to the systemic flaws within CHI, but we need a public inquiry with a cut-off date long before 2019 to capture the vast majority of the children who are still under the care of CHI. It is not good enough that we limit ourselves at this point in time to a narrowly framed commission that has been promised to families to finally give them answers. It is a failure if they walk away from today feeling that they will not get the answers from something that will cost the State a lot of money and take a long time. I am pleading with the Minister. It is time to get it right. Let us not commence until the Minister gets it right and make sure that those walking away from the Public Gallery today and all of the others watching in feel and believe that the Government and the State are behind them in getting answers for their families.

The reason we are here today is to start a process of getting answers. That is an important and significant step. I want to begin the debate with the families who have joined us here today. Within every element of Mr. Farrell's report, there are children and families who have waited too long for a proper answer, families who have had to fight against the system at every turn. In many cases, trust in the system was lost and nothing any of us says today can undo that. However, it is important we recognise what happened and the need to address it. That is the minimum this House owes to the people impacted. I acknowledge the groups who have fought and the parents who have been the force behind them. Everyone has their own story, and families have been impacted in different ways. However, like any parent who fought, it was for the best and to get what was deserved for their child. It is because of these families that we are here today, and in all the political discussions, that is what we must remain focused on. As a Government TD, I acknowledge the Minister's work in meeting and listening to the families, and more importantly, acting on this issue. She appointed Mr. Farrell, his report was published and the recommendations were immediately accepted in full. There was no further discussion or talks behind the scenes afterwards; it was a full and open recommendation. The personal stories of families who were left to wait and the issues that were let persist will now be heard. That is key. While some of us have heard stories through the media or maybe meeting with families through advocacy groups - however it was done - it is especially important now that those stories are on the record for all to see. Terms of Reference are currently being drafted and advocacy groups will be asked for input. I urge all to engage, as we have today, because all the voices from this side and the other side of the House, as well as outside it, must be put to this to shape those terms of reference. I understand parents wanted every hearing to be held in public. That frustration is real and understandable and was eloquently spoken of by my colleagues here in the House. However, this framework seeks to protect the identities of children while still allowing some proceedings to take place in public. More importantly, these families have waited too long, and as Deputy Sherlock said, hopefully it does not go on too long more. All too often in the past, we have seen and have all grown up with tribunals and processes that have gone on way too long while people wait for an answer, and that must not happen here. Let us get it right, let us get it done and let us get the right terms of reference in place so that we at least get a fair hearing for something that should have happened long before now and to ensure the system and the people behind it recognise the suffering and difficulties those families have had to deal with.

We stand at a critical crossroads for paediatric healthcare in Ireland. For years, families have looked to Children's Health Ireland and the Department of Health, trusting that their children would receive safe, timely and compassionate care. Instead, as Sinn Féin spokesperson for health Deputy Cullinane has repeatedly highlighted in the Dáil, what we have witnessed is a profound and systematic litany of failure. Our view on CHI is grounded in a simple non-negotiable principle: our children and their families must come first. We have seen heartbreaking scandals unfold, from the controversy surrounding unapproved spinal and orthopaedic procedures, leaked reports exposing deep-seated inequalities between public and private patients to a national children's hospital project whose delays are spiralling and have ballooned past €2.4 billion. Parents have rightly insisted that any public inquiry or commission of investigation into CHI must look at the whole picture, examining what truly happened to the children affected rather than just sanitising administrative systems or waiting lists. Furthermore, we believe any such inquiry must go back far enough to capture the root causes rather than arbitrarily starting the clock at 2019. It must go as far back as necessary. It is the only right thing to do. At the same time, Sinn Féin rejects a culture of concealment and corporate stonewalling. When parents learn about critical and medical reports through media leaks rather than direct communication, trust is broken. When hospital governance fails, accountability must start at the top, with the Minister for Health taking real hands-on control. Sinn Féin wants a public health service that treats the physical and mental health of our children as a fundamental human right. Fixing Children's Health Ireland means demanding transparency, backing staff on the frontline, putting patients and families at the heart of every decision, and replacing broken promises with a fully resourced, accountable, all-Ireland public health model. Our children deserve nothing less. I will finish with this. I met a young lad here as part of a delegation who had just turned 18 years of age. He had five operations cancelled and was in a wheelchair. He then ran out of time and will now spend the rest of his life in that wheelchair. That has indelibly marked my mind. I can never forget that young lad's plea for other young people coming after him. We cannot continue to let children like this down again.

First, I want to pay tribute to the parents and families in the Public Gallery, and all the campaigners who have been forced to fight for justice and truth for their children. I got a parliamentary question back from the Minister the other day after a few attempts, which revealed the cost of the scoping exercise was €241,500. The public has spent a quarter of million euro, and that in itself does not have to be a scandal. The scandal is the public has spent a quarter of a million euro and at the end of it, the vast majority of those speaking out for those affected are not happy. They say this is not what they asked for. I have many different points to make, but the fundamental point is it is years now since I made my first call in the Dáil for a public inquiry. The parents have been calling for a tribunal of inquiry for a long time, and there has been plenty of talk from the Government about centring voices and having a patient- and family-centred process, but that is not what has happened here. It has paid lip service to it. It has not happened, and we are now at the point of a scoping inquiry and recommendations that leave those families and advocacy groups fundamentally unhappy. That is what needs to be rectified. We need to go back to the approach of valuing and centring their views. Going through the different problems with what is proposed, the timeline problem has been well ventilated today. Let us be real here. What is the explanation for this very limited timeline, when clearly the problems began well in advance of 1 January 2019? Certainly, one credible explanation for what is going on here is that by having a restricted timeline, the Government restricts political accountability. Crucially, it excludes 2017 when Simon Harris promised that no child with scoliosis would have to wait longer than four months for treatment by the end of that year. Similarly, the deadline for the end of the period of 31 December 2025 seems entirely arbitrary. Scandalously, this would exclude the death of Harvey Morrison Sherratt. The second point has been made, which is the very narrow approach of Module 1 being about waiting lists. I agree we need to look at the waiting list, which has been a continuous political issue and an issue for the families, but this is too narrow. The Government needs to focus on what happened to the children. I know that might take longer and might be more painful and so on, but that is what we need to do to see what happened to these children, not just the number of people waiting for an amount of time. It has to have a wider view on the system of care, the progression of scoliosis, the deterioration of their condition and the impact on their childhoods. A crucial issue is the issue of what sort of inquiry. I obviously expect the Minister will respond at the end, but certainly at face value, these minutes from 12 December 2025 are damning, where there was a meeting with their representatives. The Tánaiste and Minister both said they did not have a settled view of the form the inquiry would take and had no difficulty with the inclusion of children who had passed away or those who had aged out of CHI services. Obviously, that is not coming to pass, but the Minister then stated that she would bring a memo to Government informing it of her intention to establish a statutory public inquiry, which would be, in principle, a tribunal of inquiry. There was no explanation for backing down from that. Everybody we are talking to says we need to have transparency and the way to have that is to have a tribunal of inquiry. That was the call from the start. The point was made by others that the Minister was also going to appoint a mediator to discuss the terms of reference, and that the interests of children were to be paramount and the mediator was to be agreed by both sides. That is not what then took place. All of that underlines the point that the Minister has not listened sufficiently to the views of the families in this. Moving on to module 2, spinal surgery, this is incredibly narrow. It is one tiny issue that was thrown out there to try to spread the blame regarding the spinal surgeries around a bit, with questions about whether the management was aware of it at a particular point in time. It is fine to have an investigation into that, but the idea that this is the only issue is incorrect. The fundamental issue is what the governance systems were that allowed one surgeon to insert non-medical grade springs. In February, I raised with the Taoiseach the issue of Connor Green getting a medical licence in Maryland. I voiced my concern about this and asked if representations were being made to the State of Maryland to warn people there to have their eyes wide open with this person and that he is no longer working in CHI because he put in those springs. I have submitted a new parliamentary question to the Minister and am awaiting a response. Dr. Green now appears to be working for LifeBridge Health. "Care Bravely" is its slogan, or whatever. This is very concerning and I request that LifeBridge Health be made aware of what happened here. I will raise two issues about module 3 and hip dysplasia. The first is the timeline of 1 January 2019 to 31 March 2025 in respect of these unnecessary hip surgeries. It was said that this module should wait the outcome of the external expert panel review before it commences, so it flows from the EEPR process. However, the starting point of the EEPR is 2010. I argued for and still maintain that the starting point for that should be 2002, when the first so-called novel osteotomies were done. I do not understand why this supposedly follows the EEPR given that some of the period and some of the children affected would not then be included in this process. Again, this seems entirely arbitrary. I also raise with the Minister that in terms of the EEPR, initially it was proposed that 45 children be excluded from it for various reasons, including comorbidities and neurological conditions, with some to be excluded in terms of time scope and some because they were operated on in other hospitals. Forty-three children have been removed and I do not understand the rationale. I do not see how a child having another medical condition affects what operation will be necessary or not. I do not understand that and I do not think there is a good rationale for the exclusion of any of those children from the EEPR. My time is running out. My main point is that the Minister needs to go back to the drawing board on this. There is no point in pursuing something that the families and advocacy groups are not signed up to and do not agree to. The answer is pretty simple. I know it requires more work and probably more expense but we should do it properly, which means a tribunal of inquiry.

We have a history in the State whereby even when we try to address mistakes made and circumstances that people have been put through, we do not go the full road we need to in relation to all those who have been adversely impacted. I was at the children's committee earlier. We had the special advocate in and we were dealing with the mother and baby homes, the residential institutions and the Magdalen laundries, and all the specific schemes and the failings within them. We discussed those who fell below the six-month limit that applies to those who lived in institutions. We talked about the boarders who were not covered. Again and again, there is an abject failure to look at the whole expanse of the wrong done and then provide a fit-for-purpose framework to deal with it. I add my voice to those voices saying there needs to be a full public statutory inquiry. We have all been contacted by people who had contacted us previously, some of whom I have spoken to and corresponded with the Minister about. I refer in particular to those who fall into the bracket of hip dysplasia. I know a mother who had three children at the time, two of whom had been through an operation that no one was quite sure was needed, while the third child was awaiting an operation. She did not trust anything offered by the State as regards second opinions. To get to the crux of the matter, we have to go back to 2019 to ensure there is no hiding place for those who have done wrong or have been part of a system that was not fit for purpose to provide care and put children through unnecessary operations. I am talking about hip dysplasia, spina bifida, right through to dealing with children with varying levels of scoliosis and the huge pain and trauma they suffer. We can imagine what parents have been put through and all the worry of wondering whether their child should have had the operation and if they did the wrong thing. I met parents who were very lucky that they had looked for a second opinion and did not go through with operations as a result. It is unfortunate that others did not fall into this bracket. We can go around and around the garden on this but the fact is we need the terms of reference to be right. We need to make sure the timeline is right. I know people are very worried about the timeframes that they believe this will be followed through on. We need to make sure we provide the service that will give the care that is needed for some of the most vulnerable children in our society.

I too welcome the families and campaigners in the Gallery and pay tribute to the work they have done to try to achieve truth and justice. I disagree with an Teachta Ó Murchú's point that there has been a failure in this country to achieve justice. Rather, there is a clear strategy by the Government not to achieve truth and justice on these matters. I want to look at the architecture of that. First, in any of these situations, there is often a family or a campaign group that has battled for years for fairer treatment or against a grave wrongdoing, or even sometimes a criminal act that has been carried out by agencies of the State. The second step is where campaigners have to put a mountain of pressure on the Government to get it into a situation where backs are against the wall and it is forced to accede to doing something. The third step is that the Government is then forced to meet the families. The Government will often then speak sorrowfully and in measured tones. It accepts there has been wrongdoing and promises justice for the families. It promises to put the families at the heart of an investigation process to make sure it takes direction from the victims and survivors to achieve justice. However, in the next stage, when that mountain of pressure subsides and the story falls off the front pages, the Government waters down or even quietly deletes the commitment it has made to those families. It then carries out a narrow, limited investigation that protects the vested interests of Government Ministers and ignores what is at the heart of the crisis. We have seen this before with CervicalCheck and the Women of Honour and we see it now with the families at the heart of the CHI crisis. I have been here for 15 years and may be cynical, but this has all the hallmarks of a communications consultancy template for crisis management for a government. It is horrendous and disgusting. It is a slap in the face to victims and survivors. This time last year, parents of children who had died had to pour their grief into the public domain over and over again in order to shock this Government into doing its job. This time last year, mothers had to come to the audiovisual room to discuss their experience with CHI. They told of the deaths of their children and of children living with continuous and extreme pain. They spoke about lungs and stomachs being crushed. They spoke of children who were left disabled for the lack of treatment. Images were shown of rods breaking through the skin of children waiting for treatment. We heard of children suffering infertility and higher rates of cancer because of the lack of treatment. The group also told us of the toxic management culture within CHI and the bullying of staff and parents. We heard of taxpayers' money being spent without oversight, the insertion of unauthorised springs into children and hundreds of children undergoing unnecessary operations. To put maximum pressure on the Government, we played our part. We in Aontú tabled a motion of no confidence in the Tánaiste, who was the Minister for Health who promised that no child would go over four months without an operation. The Tánaiste failed in that, as has every other Minister for Health since. To puncture that pressure, the Government brought the families and advocates of those children who had been so grievously wronged to meet the Tánaiste and the Minister. We can see from the minutes that the Minister and the Tánaiste gave a solemn commitment on key issues that would underpin these investigations. Today, those commitments are in tatters. They are shredded. The Minister can distract and say that these decisions were made by Remy Farrell. The Minister has the Executive's authority. She made those commitments. As we stand here today, there is no tribunal of inquiry, as was promised by the Ministers. There is no agreed mediator or independent clinical expert. There has been no direct consultation with children. There has been no further meaningful engagement with families and the timescale of this investigation strategically dodges the time when the Tánaiste was the Minister for Health. That is not an accident. It is the core. The first issue on the agenda in any of these situations is how to protect the Ministers involved. The Minister is breaking solemn commitments to those children. I ask her to reverse from this counterfeit commission of investigation and listen to the families.

I listened to the Minister's speech. To be clear, what she and the Government are offering does not meet the core demands of the families who are still living with trauma or those who have suffered in the past, including those who have lost loved ones. In fact, it is dangerously short of what is required to fix the broken system. As for justice for those families, what justice? Along with other Opposition Deputies, I believe that the choice of a commission of investigation is wrong. By law, a commission conducts its work in private by default and parents do not want an inquiry behind closed doors. Some do, and there is a win-win in that regard. The crisis demands public transparency and executive accountability. I and others are calling for a full statutory tribunal of inquiry. Under the tribunal model, the default setting might be entirely public in ensuring that Children's Health Ireland and the Department of Health are held publicly accountable. However, the law retains the flexible power to move into private sessions either to protect the medical privacy of individual children or for whoever does not wish to be in the public domain. It is important to have that tribunal because trust has been broken. We must remember that the Government's unilateral appointment of Remy Farrell SC as the scoping lead completely bypassed families. They were excluded from inputting into the process. It is no wonder that the Scoliosis Advocacy Network and Spina Bifida Hydrocephalus Paediatric Advocacy Group, representing some 900 families, felt compelled to formally withdraw from the process in June. Their view remains that it is already a top-down, fundamentally flawed exercise. While CHI coming to an end is, of course, welcome, the current impasse cannot be resolved while any part of the Department of Health controls an investigative process. The Department and the HSE are active subjects in this scandal. You cannot self-investigate even if we can get an agreed independent person to conduct an inquiry or, we hope, a tribunal. To break this deadlock, we need the immediate appointment of an independent, mutually agreed mediator from outside the Department of Health. This process must then be moved entirely outside the remit of the Minister. I accept her bona fides, but those affected do not trust the Department or the HSE. Therefore, the inquiry should be moved to the Department of the Taoiseach, as others have stated, and families should be given an input into helping to design the terms of reference as equal stakeholders. As others have said, capping the timeline of this inquiry at 2019 to match the creation of CHI is narrowing the scope way too much. Hip dysplasia goes back to 2002, or at least 2010. The Crumlin orphans transfer goes back to 2008 - a year, incidentally, when the State disbanded routine scoliosis screening programmes in schools, which would be another good starting point. There is also the tipping point for the waiting list crisis, the first crisis point of which was in 2014. It is clear that systemic negligence did not begin in 2019. By using the 2019 cut-off, the State is erasing a timeline of neglect suffered by an entire generation of older children and young adults. Furthermore, while the Nyagam look-back is an essential clinical safety audit, and phase 2 is dragging on, it is completely insufficient on its own. It focuses on the practice of a single consultant and does not address the core institutional blind spots that allowed the unapproved medical devices to be used in the first place. We need a wider investigation that looks beyond one doctor, scrutinises the entire executive governance structure of CHI and, crucially, its predecessor, shows how we have learned from this and ensures things will be better, going forward. The families are owed a response that address the human cost of the crisis over the years. That means any process must formally include those children who have tragically passed away while waiting for care and the young adults who have aged out of the paediatric services without ever receiving the treatment they were promised. Separately, any inquiry needs a State-guaranteed transition pathway to be established right now to move vulnerable children safely through the system while these legal reviews drag on. We cannot put everything in stasis while we are waiting. I urge the Minister to consider the tribunal route.

I assure the Deputy that we are already developing those transitional pathways. That is not contingent on any other external processes. I thank the many Deputies who contributed to this important debate. I reject Deputy Tóibín's assertion that this is any sort of communications or political exercise. This is very definitely not that. I thank Deputies Cullinane, Sherlock, Rice and Murphy, in particular, for their deep knowledge of this subject and for their constructive engagement on behalf of families and in trying to reach a method that is going to achieve what we all want to achieve, which is a way of ensuring that we have a statutory investigation. I appreciate that different views were articulated here than were articulated in the report but we require a statutory investigation into those things that should not have happened, most particularly and importantly the ongoing failure to care for children with significant needs and the lack of knowledge where there should have been knowledge within a structure that was created, funded and supported by the State. I hope that in my opening remarks I set out accurately the different elements of what Mr. Farrell tried to achieve in his report. I said to Deputies privately that I wanted to hear from them before taking on any next stage. There are important parts that I want to recap. The scoping exercise was established precisely to try to get the broadest range of input possible. Mr. Farrell said clearly that he is coming to this as a senior counsel without a body of knowledge of the topic. He is not a Member of the Oireachtas. He has not worked in this space. He states clearly in the report - I cannot quote the page but Deputies know it is there - how important the patient voice was to him, how it informed him in a way that the documents did not, how much he wanted to achieve the broadest participation of the patient voice directly and how much he welcomed the groups and individuals who came to him or were brought to him by different advocacy groups or reference points. Indeed, he asked me to extend the opportunity for broader participation of the patient voice. I absolutely respect that nobody is required to participate in any process. I have full respect for that. However, I would have welcomed broader participation in a system that was designed to try to capture as many voices as possible and which had a particular impact on Mr. Farrell. He highlights that most acutely in respect of the Crumlin orphans but, more broadly, he highlights the impact of the patient voice. The process was an effort to distance this from the Department of Health. We appointed somebody and then did not get involved in any way specifically to try to protect the independence of Mr. Farrell and to keep it away from the Department. There may have been correspondence or requests for me to do X, Y or Z but we deliberately tried to keep this separate from the Department of Health because I very definitely respect and recognise a view that there is a historical difficulty there. Two Deputies have asked for that process to be moved to the Department of the Taoiseach. I personally have no difficulty with that – I really do not. This is a collective Government response in any event and it is very important that it be independent. In that sense, it is correctly recognised that the ultimate process does need a measure of independent clinical advice. It cannot be that it is a lawyer on their own. That is a process to establish that. Deputies have raised with me in different contexts the opportunity to have an overall chair and potentially multiple seats at the same time. Again, that is something we can reflect on. Nobody wants a process that is going to go on forever. Everyone wants the most comprehensive process possible. Those different pieces are very important. It is also important to say that Mr. Farrell specifically mentioned the group of children referred to as Crumlin orphans, the children who were entirely let down by a transition of services from one hospital to another and not supported in a way they needed. The way he reflects on that is similar to my personal view, which is that it is an effort to try to be inclusive rather than excluding. He specifically notes how that group was treated. He puts a reference point on it of 2019 but goes further back in relation to that group. I have spoken to Deputies on how we do that. The purpose of the patient and family voice is to replicate in many ways the positive experience Mr. Farrell had by listening to patients and families directly. That is the point and Deputies have said that in different ways. It is to listen to as many voices as possible because they inform the other questions. When you listen to a family, it informs the other more systemic questions that need to be asked, so it is a question of how we include as many people as possible and what the correct reference point is. It is also true that any process we establish has to have defined periods. We know that from our previous experience. The degree to which we can enable discretion and flexibility in those different processes is more particularly advanced with the case of the commission over the tribunal precisely because it enables different forms of the private opportunity as the default. With tribunals, I have real concerns about a parent, family or child advancing a particular case in public and that they then end up in a cross-examination situation by lawyers for a particular medic. That is not something that I want to happen. We think about this as the opportunity potentially to question medics, but a tribunal also potentially means senior counsel questioning parents. We have to be careful about the meaning of these different things in both directions and how we protect children who have their own independent rights under the Constitution and how their legal rights are protected. There is no desire to exclude but a real desire to recognise some of those parameters. It is not my job as Minister for Health to tell people things that cannot happen. For example, it would be completely wrong of me, as it would be of any other person, to tell people that a statutory inquiry can get an individual resolution or an individual measure of justice in an individual case. That is not provided for in the legislation. There are different processes, both legal and medical, that examine that. It was put to me about misleading families or telling them things, but that is not the structure of this inquiry. Any inquiry, whether it is a tribunal or commission, is not an exercise of resolving outcomes in that way. They are exercises of finding fact in a historical way about what broadly went on. There is no question that is greatly improved and enhanced by the very direct voices of patients and families as they choose to bring that to any inquiry, but it cannot reconcile individual cases and it would be wrong to say that it can. Any person who says that is possible needs to look at the legislation and the purpose of commissions and how they have worked in the past. I ask Deputies to forgive me. I have had a head cold today and I do not mean to be inattentive at any point. I would mention two elements of Mr. Farrell’s report in particular where he has tried to provide a rationale for why he might have included or excluded something. He explains why he suggested that Temple Street be included in the spinal surgery module and not Crumlin. He says it was suggested to him that some clinicians argued that if Temple Street were investigated, then similar scrutiny should apply to Crumlin. That again speaks to the cultural dysfunction that existed between the two hospitals. Mr. Farrell acknowledges the argument but totally rejects it on the basis that the controversy related primarily to Temple Street and they were specific to Temple Street. He has analysed the information and cross-referenced it against the two hospitals. Conversely, in relation to hip dysplasia and the external expert panel review about the importance of the patient voice, he notes the external expert panel review is limited to examining the records and radiological evidence and that it does not interview families or clinicians, as such, or take witness evidence or examine conversations that took place before surgery. He specifically notes why it is so important that parents and their experiences should form part of an inquiry: because it is essentially to understand what happened in individual cases relating to information received, treatment options, including alternative treatments, and how decisions were made, and crucially, whether they gave fully informed consent for surgery. What I am saying is there was a logic to what he included and excluded and a real effort to amplify the voices of patients in different ways. I recognise there are different views on that but they are broad parameters. We will have a statutory public inquiry which Mr. Farrell says is a commission of investigation. I see very good reasons that should be so. We are going to have a module for parents and families to describe their experiences. That may be in public but I would like to give them the choice rather than define that in this House. I will reflect on how we create the opportunity, as has been said here and elsewhere, for children prior to 2019 whose experience is important in how it informs everything else that happened. Mr. Farrell already recognises that in his proposed terms of reference. There are other discreet ways of doing that too. I am genuinely trying to find a balance of something that can function and deliver a historical report and really hear the voices of families and children who are at the centre of this.