Dr. Tony Holohan:

If I may, I will leave the second question to the HSE. On the first question, I cannot say whether the actual incidents were directly the responsibility of consultants, but each of the two patients - the subject of these "never events" - was under the clinical care of a consultant who had overall responsibility for the care delivered to that patient. In that sense, the consultants have a responsibility.

I left out Deputy Ó Caoláin's question regarding perinatal death data, for which I apologise. There is a paragraph in the report that tries to summarise or explain the gaps in the data. It says that the General Registrar Office, GRO, receives a higher number of stillbirth notifications than the National Perinatal Reporting System, NPRS. Even though such notifications come from the same location, the GRO gets a higher number of stillbirths notified to it and it reports on them. With regard to the other component of perinatal deaths, known as early neonatal deaths, covering death up to seven days of life, the NPRS gets more early neonatal death notifications than the GRO. There is under-reporting and under-registration of early neonatal deaths to the GRO. That finding in the report is one that I am not sure anyone was aware of. A statistician from the CSO who works with us in the Department and a public health specialist worked solidly for seven days analysing all of the different sets of data, and their work provides the basis for the eight-page analysis set out in the report.

We have made it available to the Department of Social Protection and we will be in discussion with the Department in respect of what needs to be done to tighten it up and ensure we are reporting on the same, and the correct, definition. Our recommendation is that the hybrid, which corrects the two under-reporting factors, is used but it will not make any difference to our overall ranking. The idea that this is a complete misrepresentation of what our perinatal mortality rates says about the safety of our system is not the case. What we observe in respect of perinatal mortality is that, given that information available in units is not being looked at, perhaps an undue over-reliance on the perinatal system, referred to as the "burglar alarm" by the Minister, is not appropriate to be examined in isolation.