Dr. Tony Holohan:

All we have looked at is the hospital in Portlaoise. We talked to patients and families who were users of the service and we talked to the staff and those who had leadership responsibilities. It appears that a complex culture developed over time and, without wishing to sensationalise, it is very similar to the findings that were set out in the Mid Staffordshire investigation in the UK. That same sort of culture that has been the subject of a lot of writing in the UK was evident here.