Dr. Tony Holohan:

What happens is that all adverse incidents are the subject of reports. They are completed and sent to the State Claims Agency which makes them available to hospitals. I know that the agency has participated in some learning and feedback arrangements to obstetric units, particularly where there are concerns about the levels of obstetric claims generally, as a way of trying to extract learning from adverse incidents. We know that the level of reporting is variable as between services and professionals. Frankly, in general terms, nurses are much better at reporting than doctors who are not necessarily always good at reporting comprehensively on adverse incidents. We have made a recommendation in the report which the HSE has accepted and is in the process of implementing, that what are called "never events" become the subject of mandatory reporting to both the national director of quality and patient safety and the HSE and HIQA. Therefore, it will create visibility immediately around the serious events that we saw in Portlaoise hospital, the six about which we have spoken.