Dr. Tony Holohan:

This is recommended in the report. We do not need to have another investigation of this kind or another report of this kind to tell us that we need to get on with that reform. It was already part of the direction of travel and we are saying that it needs to happen forthwith. There are similar-sized units in other parts of the country. We did not investigate them so we cannot say that any of the problems we found in Portlaoise are happening there but some of the ingredients that are important in explaining what happened are evident in some of those smaller units. In that context, there is a justification for proceeding quickly with the direction of travel.

The coronial process was mentioned a number of times and questions were raised about the timeliness of it. In one case a family was waiting for a number of years for a coroner's inquest to take place, while another family, for whom the incident took place at a much later date, went through the inquest at more or less the same time. That added to the family's distress. As I said earlier, we have already commenced a process of engagement with the Department of Justice and Equality regarding this issue. A report was published in 2000 on the coroner process which provided the basis for amendments to the 1962 Act in 2005. A draft Bill was prepared and it was recommended at the time that a national coroner service be established, along with other measures which are still being examined by the Department of Justice and Equality. We want to engage with the Department to make sure that some of our findings are reflected in its review and its plans to update the legislation.

Senator Colm Burke asked a specific question about management turnover; the HSE might be in a better position to answer that. Without getting into semantics, it is important to point out, in the context of what Senator Crown had to say, that this was not a training location on the specialist registrar, SpR, training programme in obstetrics and gynaecology, although at least one individual was part of basic specialist training, BST, training in obstetrics. It is a training location in both obstetrics and paediatrics as part of the local GP training scheme but there was no specialty-specific training happening in Portlaoise. These people were not trainees. The junior hospital doctors were in service posts. I should have added, in what I said about staffing, that the report sets out the data very clearly on what has been a fairly recent trend towards increasing dependence on agency staffing in both medical and junior hospital doctor provision, whereby the expenditure on agencies for that service is somewhere in the region of €1 million now as against an expenditure of zero in 2007-08.

I hope I have answered Deputy Neville's question about whether what happened at Portlaoise is happening elsewhere. I may have missed a question or two along the way and am happy to be reminded of them if so.