Catherine Murphy T.D. (Kildare North) Public Accounts Committee

With regard to the list of actions where there are groups of people affected in the same way – mass action as opposed to class actions – how many would be grouped if it was to be described as a mass action? How many claims would there be if they were to be put into a category like that?

Mr. Ciarán Breen – State Claims Agency

It will depend. In other words, what normally happens is that we will either get one claim or maybe a dozen will come in together.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

If there was a dozen—–

Mr. Ciarán Breen – State Claims Agency

We would say that is a mass action.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

What about the list the agency has given us

Mr. Ciarán Breen – State Claims Agency

That is a good indication of the numbers pleading similar things.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Are there many more like that?

Mr. Ciarán Breen – State Claims Agency

We have set out in the report exactly what they are.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Are the ones in the report the only ones Mr. Breen would describe in that way?

Mr. Ciarán Breen – State Claims Agency

Some new ones have come along in the meantime.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

What would the new ones be?

Mr. Ciarán Breen – State Claims Agency

For example, there are 26 cases in regard to transvaginal implants. There is sodium valproate, which is a potential mass action. Where there is another abuser, there may be a set of claims which attach to him. We have Gardasil, which is the HPV vaccine, and we have Aulin, which is another medicinal product.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

In regard to the Air Corps, the agency has 21 active claims. Mr. Breen has not mentioned that.

Mr. Ciarán Breen – State Claims Agency

I am sorry, I did not mean to leave them out. The Deputy is right that we have a number of cases from the Air Corps in regard to alleged exposure to chemicals.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

The State Claims Agency would have had an involvement in risk management. I received a reply to a parliamentary question from the Minister the State, which stated:

I am advised by the State Claims Agency that it has a statutory remit under the National Treasury Management Agency (Amendment) Act 2000 to provide risk management advices to Delegated State Authorities. … [The] State Claims Agency conducted a number of Health & Safety Management System Defence Forces audits within the Air Corps between the years 2006 – 2015. The Reports are authored by the State Claims Agency and are confidential between the Agency and their Client [which is the Department of Defence].

What would the agency have looked at when it went out to do those assessments? Would it have looked at the paperwork, and would it have gone down to the level of looking at what equipment people are wearing to protect them or the environment they are working in?

Mr. Ciarán Breen – State Claims Agency

The Defence Forces has put a safety management system in place, and this applies to all branches of the Defence Forces. We have worked very closely with them in that regard. On risk, our people on the ground, when they carry out audits, go onsite and they meet with the person who would have responsibility for safety and health in the particular barracks, battalion or otherwise. They carry out audits of things like, for example, what is being done about lifting and the safety standards in respect of that.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Would it have looked at chemicals, for example, where chemicals are sited or how they are handled? Would it have looked at the kind of things that would expose people to risk?

Mr. Ciarán Breen – State Claims Agency

I want to explain the position in regard to the Air Corps because I believe it might be helpful in answering specifically what happened. We started our audits there in 2006. The particular exposure we are looking at in respect of the chemicals in the Air Corps is from 1972 to 2007. In 2007, the particular workshop which is associated with the alleged exposure was changed to a state-of-the-art facility. At no time—–

INTERRUPTION by PAC Chair Seán Fleming

Mr. Ciarán Breen – State Claims Agency

At no time during those audits and reviews was anything specifically brought to our attention about the historical exposure, if there was one, that might have been there and how that was handled. We were very assured by the fact it was now a state-of-the-art facility.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

The agency would not have looked at—–

Mr. Ciarán Breen – State Claims Agency

The exposure long predated even our establishment.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

I have been given a document, which I might have mentioned before, on the extraordinary age profile of people who have died in the Air Corps. The Air Corps is not a big employer and there have been 72 deaths at pre-retirement age, some of them very young. Of the 72, 14 or 15 are by suicide but others are in particular categories, such as cancers and cardiac issues. It seems a very dangerous place to work – I am sorry, I do not really mean that, but it seems to be a place where an abnormal number of people die prematurely. That would have jumped out to me as something that would make me question the risk. As Mr. Breen said, it goes back to a time prior to when the agency was doing its assessment. I understand there were no registers of this particular chemical available.

Mr. Ciarán Breen – State Claims Agency

I am not sure. Is Mr. Kirwan is in a position to comment on that?

Mr. Pat Kirwan – State Claims Agency

Not specifically. The chemicals that are discussed in the statement of claim are a wide range of chemicals, basically organic lubricants and degreasers. I do not have that information or the Deputy would need to be more specific about the particular chemical she is talking about.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

I have the names of the—–

Mr. Pat Kirwan – State Claims Agency

I know that when we audited there, we were satisfied that, for the chemicals that were in the workshops – I am talking in a general sense – there where material safety data sheets available for any chemical that we sampled. That would suggest they were registered in some way.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

I am trying to find out how to mitigate risk and I am using this as an example. What I am hearing is that there still is not, or there was not in recent years, use of protective clothing and availability of a particular type of protective clothing when handling these materials. Would the State Claims Agency have looked at that, given it would have known the profile? Is the agency satisfied the risk assessment is mitigating this risk?

Mr. Pat Kirwan – State Claims Agency

I head up the enterprise risk unit that would have carried out the audits.

When we go out, we look at the systems that are in place. We are back to that word, “systems”, again. We sample as we go out. They are snapshots. One is only there for a particular day. We talked to the staff and the members of the Defence Forces who were available in the workshop. They are highly-trained, technical people. We came across no evidence of procedures or practices being carried out to anything other than the appropriate standards at that time.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

I understand that the Air Corps does not carry out mandatory risk assessments. Does the SCA not instruct particular organisations to carry out mandatory risk assessments? Is that not essential?

Mr. Pat Kirwan – State Claims Agency

Absolutely. It is not only essential from the point of view of the agency’s expectations, but it is also a legal requirement under the Safety, Health and Welfare at Work Act 2005. Again, that was not our experience. Ultimately the Defence Forces are responsible for the risks. When we originally worked with the Defence Forces they had risk assessments in place. In organisations as complex as the Defence Forces, the Naval Service, the Air Corps, and the Army, we are talking about thousands of different types of risk assessments. I cannot vouch for any particular risk assessment but, in general, the Defence Forces do have risk assessments in place.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Are they mandatory?

Mr. Pat Kirwan – State Claims Agency

It is mandatory under Irish legislation for appropriate risk assessments to be in place. It is also absolutely mandatory as part of the occupational health and safety management system the Defence Forces have had in place for some time.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

What the does the SCA do? Does it visit, carry out the assessment, and give the Defence Forces a certificate? Is there a certificate for each year? Were there years in which they were not given a clean bill of health?

Mr. Pat Kirwan – State Claims Agency

There are approximately 56 units in the Defence Forces. We cannot possibly audit every single one every year. We carried out approximately 100 audits between 2006 and 2015. An audit might be themed, that is, we might be looking at particular themes. For example, we may be worried about appropriate training documentation because that is something we have learned about from dealing with claims. We may have seen a number of incidents of a given type. For example, we may have seen particular injuries arising from vehicle crashes. For that reason we might look at that aspect of the system in particular. In general we look at roles and responsibilities, the structures that are in place, and the types of risk assessments and documentation that are in place.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Does the SCA work with the Health and Safety Authority on any of this?

Mr. Pat Kirwan – State Claims Agency

No. We have worked collaboratively with the Health and Safety Authority to produce guidelines in respect of, for example, schools, critical incidents and stress management. We have a different role in this area however. It is a policing authority and enforces legislation. On the specific issue of chemicals in the Air Corps, we were involved with the Healthy and Safety Authority in the sense that, after going in and carrying out one of its inspections, it made some recommendations and advised the Defence Forces to consult with us in addressing those recommendations.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Did the Health and Safety Authority not threaten legal action over shortcomings in the use of chemicals?

Mr. Pat Kirwan – State Claims Agency

I am not—–

Catherine Murphy T.D. (Kildare North)Public Accounts Committee

It is my understanding that it did.

Mr. Pat Kirwan – State Claims Agency

I am not exactly sure and I would not like to speak on the Health and Safety Authority’s behalf. I do know that it audited the Air Corps and raised issues. I am not sure of the level at which they were raised. We were active in helping the Defence Forces to address those issues to the satisfaction of the Health and Safety Authority.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

It is my understanding that the authority did threaten legal action. It seems extraordinary that one arm of the State may be doing so while another is giving the Air Corps a clean bill of health with regard to risk. That does not stack up in terms of mitigating risk into the future.

Mr. Pat Kirwan – State Claims Agency

Again, I would have to know the specific details to comment but statutory legislation underpins the health and safety of our employees across the State sector and, indeed, all employees within the State. With regard to chemical safety in particular, there is a complex suite of legislation in place. There is legislation from 2001, 2007, 2010 and, most recently, 2018. In addition, there is guidance in that area. It moves. In other words—–

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

The SCA is not expert in all of this, so does it have to bring in people who are experts in a given area?

Mr. Pat Kirwan – State Claims Agency

We are experts in this area. Members of our enterprise risk management team have backgrounds in engineering, science, public health, and nursing. Most have, at a minimum, a degree level qualification. Many have masters and some have doctorates. They are experts in various areas. We have expertise right across the main areas one would expect to encounter in dealing with employee and public safety. We are a very expert unit. We publish national and international guidelines. We are recognised as such.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

How many people work in Mr. Kirwan’s unit?

Mr. Pat Kirwan – State Claims Agency

We have 20 members of staff.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Most of these people have professional qualifications. Are there administrative staff included in that 20?

Mr. Pat Kirwan – State Claims Agency

There may be two administrative staff members included in that 20. The others have worked at very senior levels in the Defence Forces, the Health and Safety Authority, and other semi-State and private organisations nationwide, usually in some area of environmental or public health and safety.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Is there a bonus system or anything of that nature in the agency for mitigating risks?

Mr Ciarán Breen – State Claims Agency

Is the Deputy asking whether we operate such a scheme for State authorities?

Catherine Murphy T.D. (Kildare North)Public Accounts Committee

Yes.

Mr Ciarán Breen – State Claims Agency

No, we do not. There is no kind of risk-pooling approach in the public service. That does not happen. Every year, however, we ourselves recognise individual State authorities in a ceremony we hold at one point in the year. We give certificates to authorities that have done something very particular to mitigate their risk, and which produce documentation to prove it, at an annual event.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

We saw some evidence of that the last time the SCA was before the committee. We could see serious progress with regard to slips and falls. That is to be commended. I am still not entirely clear what the SCA looks at when it goes out to such organisations to look at issues such as the handling of serious chemicals. Does it look at whether adequate equipment, such as gloves or clothing, is provided to reduce the risks? Does it evaluate risk at that level?

Mr Pat Kirwan – State Claims Agency

I fully understand that it is quite difficult to understand. There are thousands of risks in, for example, a large facility such as that of the Air Corps in Baldonnel. We have to be guided by what we see, for example, reported on the national incident management system. At no time did we see any significant level of reported incidents relating to chemicals. In other words, it was not flagged to us as a hotspot to investigate. Nonetheless, because, as I said, chemical safety is important in workshops, it is something we test. I use the word “test”. In other words, we sample. On the day, we talk to people, we look at how the chemicals are stored, and we ensure the appropriate documentation is in place.

Perhaps I should give an alternative example. We did a very large job with the Defence Forces with regard to the guarding of machinery. We did so because there had been incidents of people being seriously injured because guards were not in place. We looked at a series of workshops. In that case, some workshops were closed down and some machines had to be retrofitted. That investigation proceeded machine by machine. We looked at it in detail because we, as a claims agency, saw it as a definite source of litigation risk.

The Deputy talked about the Health and Safety Authority. It will be guided by the statutory legislation. We obviously consider what we are particularly concerned about that could lead to claims. One of the indicators is whether incidents are being reported.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

On those cases, are they ongoing, settled or in dispute?

Mr Ciarán Breen – State Claims Agency

They are ongoing. One is in the Court of Appeal. A date has been given for the year after next because there is a glut of appeals in that court. Others are awaiting an important decision by the Supreme Court on a discovery issue.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

When mediation is possible for a group, but not necessarily the group in question, how does it happen? If there are a dozen cases coming in on something or other, does the agency wait for one case to be proven in the court? What approach does the agency take?

Mr Ciarán Breen – State Claims Agency

We do not have what in the United States and certain other jurisdictions is called class action, whereby a whole series of cases is taken at the one time, or for the group. Here a lead case will be chosen by a plaintiff’s solicitor, and it will be agreed with us that it will be the lead case. We engage on that case in terms of our separate investigations. One can imagine that we are preoccupied with the question of whether the State has a liability. Where it does, we obviously want to settle at the earliest possible opportunity. One of the vehicles we might use for that is mediation, if it comes to that. Having settled one, we would be of the view that unless the other cases could be differentiated in some way, we should seek to settle them through incurring the best possible cost and as quickly as we could.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

On Cervical Check, a couple of years ago we saw Vicky Phelan going public. If she had not done so, would others have realised they could have been affected in the same way? Is that used as a means of mitigating against damage done to individuals? I am referring to settling with what is known as a gagging order.

Mr Ciarán Breen – State Claims Agency

As the Deputy knows, we were not party to any of that. That case was settled by the particular laboratory.

Catherine Murphy T.D. (Kildare North) Public Accounts Committee

Yes

Mr Ciarán Breen – State Claims Agency

We were only involved peripherally in relation to the non-disclosure part of the case. I understand the point the Deputy is making, however. We talked on the last occasion I was here about how the other women found out. That is a different issue.

*****

The State Claims Agency Risk Management Section commenced annual Health & Safety Management System audits in 2006.

Unprotected toxic chemical exposures continued in the Irish Air Corps until they were threatened with legal action by Health & Safety Authority in 2016 for serious and basic Health & Safety failings that were an immediate threat to personnel after 2 x technicians were injured by solvent exposure in late 2015.

Luxuries such as gloves, eye protection & respirators were finally issued to all relevant personnel in 2017, a full two decades after another state agency Forbairt recommenced same in 1997.

Despite several legal actions, despite a decade of risk audits by the State Claims Agency, despite legal threats from the Health & Safety Authority the Irish Air Corps still thought it was OK to publish the below photographs on their official Facebook page showing ongoing chemical health & safety breaches in 2018…the Air Corps blamed this on “personal failings”.

Delay – Deny – Die

Catherine Murphy T.D. (Kildare North)Public Accounts Committee

Watch Deputy Catherine Murphy question Mr. Ciaran Breen, Director of the State Claims Agency and Mr. Pat Kirwan,  Head of Enterprise Risk, also at the State Claims Agency, about the failure of a decade of Risk Management Section, Heath & Safety Management System audits at Casement Aerodrome, Baldonnel.

The State Claims Agency audits at Baldonnel commenced in 2006 and continued as the Irish Air Corps were investigated by the Health & Safety Authority in 2016 for serious breaches of the Safety, Health & Welfare at Work Act 2005. Breaches that including the very basic failure to provide PPE or chemical training.

It took the threat of legal action by the Health & Safety Authority as well as 2 years & 9 months of intervention to finally close the HSA file on what their own inspectors described as the most serious case of chemical misuse in the history of the state.

It should be noted that the State Claims Agency were not only aware from 2013 that the unprotected chemical exposures at Baldonnel were an ONGOING LIVE ISSUE, but bizarrely failed to intervene to prevent further exposure once this knowledge was in their possession.

It took the actions of three whistle-blowers in 2015 to bring the ongoing toxic chemical Health & Safety failures at the Irish Air Corps to the attention of the Minister for Defence and also to the attention of the Health & Safety Authority.

Why did the State Claims Agency fail to notice the high rate of untimely mortality, the high rate of suicide, the high rate of sick leave, the lack of PPE records and the lack of any chemical training records in 10 years of supposed audits.

Why did the State Claims Agency fail to act in 2013 when they did become aware that personnel were still being needlessly exposed to dangerous chemicals without PPE and without any chemical safety training?