In the HSE, nobody is ever responsible for mistakes
In early 2014, as she stood down after seven-and-a-half years as head of Hiqa, the health service watchdog, Dr Tracey Cooper's parting shot was: "We have not yet cracked accountability. Whenever something goes wrong, nothing happens."
Since then, little or nothing has happened to enhance the system of accountability in the HSE. This week, we heard the heartbreaking story of 'Grace', who was allegedly savagely abused over a period of 20 years under the noses of HSE managers, some of whom may possibly have been promoted since then and carry responsibility, as we speak, for ensuring a safe service for defenceless people entrusted to their care.
Following last year's HIQA report into infant deaths in Portlaoise hospital, there were calls for sanctions against personnel who had failed "to take seriously" the evidence of repeated catastrophic failures that were brought to their attention.
The best that the CEO of the HSE, Tony O'Brien, could offer when he was pressed about sanctions was to appoint HR consultants from the UK to advise on how these serious failures by several layers of management could be handled.
Here, we have the biggest employer in the country, with over 100,000 staff, which doesn't have an effective performance-management and disciplinary system, one that includes, when required, the legal instruments and industrial relations machinery to impose sanctions on managers guilty of the most egregious lapses.
Questioned before the Public Accounts Committee this week, Mr O'Brien explained how he was powerless to take effective action and, turning the spotlight on his interrogators, he then added wryly: "Because of rules set in this place."
In this context, Mr O'Brien told a Dáil committee before Christmas that there is no consensus around a vision for our health service. A few days later, the Taoiseach said that this lack of clear direction resulted in "haphazard" initiatives.
All of this is an indictment of our politics, senior civil service and HSE top brass.
While some frontline staff have been found to be in breach of expected standards in certain cases, the main focus has to be on management, from supervisors right up to the most senior executives, civil servants and Government ministers.
Nine staff missed 13 opportunities to intervene in the tragic case of Savita Halappanavar, which indicates the absence of a system of rules and procedures that apply along the care pathway, rather than human error or negligence.
It is managers and clinical leads who are responsible for ensuring the design, implementation, monitoring and continuous improvement of such systems.
It is managers and clinical leads who were responsible for the fact that, two years after an investigation into the death of Tania McCabe in similar circumstances, new procedures specified for the treatment of sepsis had been implemented in only six out of 18 maternity units.
The Portlaoise report stated that if the findings of six previous reports into medical failures in other hospitals had been implemented in Portlaoise, the sequence of infant deaths there could have been avoided. Do hospital managers and clinicians even bother to read these reports?
When 'adverse incidents' occur, the instinct of those in charge too often appears to be to go into a huddle, close ranks and figure out how to contain the situation.
The catalogue of neglect and incompetence testifies to the deep-seated antipathy to accountability in our health and social care system.
Tearful parents on the steps of the courts every week testify to the battle that individual citizens have in seeking justice for death and injury to their loved ones.
The Irish philosopher, Philip Pettit, says in his book 'Just Freedom: a Moral Compass for a Complex World', that these battles between the citizen and the State are unequal because the State has bottomless pockets, endless patience and, crucially, the cloak of anonymity that pre-empts personal accountability.
Anonymity is not confined to the HSE. When proper investigations eventually get to the bottom of various scandals, the names of culpable individuals are redacted, obliterated by a black marker, from the reports.
As a society, our systems of accountability are a sham. Even perjury is not treated as a crime.
We should not have to rely on whistleblowers, hidden cameras and legal battles to eliminate, or at least reduce, the seemingly endless spate of harrowing stories emanating from our health and social care services. The key is to embed grown-up systems of governance and accountability, that is personal accountability, with implication of consequences arising from unacceptable failure.
As the Bible says: "Without a vision the people perish" (Proverbs 28:18). How true of our health and social care service.
The priority for the next government must be to work with external experts and senior HSE people to articulate the required comprehensive, coherent vision, including unambiguous structures, processes and legal instruments, that make possible personal accountability at every level.
Cracking managerial accountability is ultimately more important than delivering on yet another haphazard list of politically motivated pre-election palliatives.
Eddie Molloy is a management consultant.