Dr. Philip Crowley:

Our intention all along with regard to the review was to investigate as properly as possible all of the facts and root causes of what led to the tragic events in Galway. The purpose of this in the first instance is to ensure if any elements arise in the investigation which suggest there could be any potential risk or harm to any other woman attended our maternity services that we address it immediately and that we do not await the end of an investigation or an inquest process which can take longer.

It is our policy to investigate ourselves when adverse events occur. As Mr. O'Brien stated, in many instances this may be done effectively by local staff in a local institution with national incident management team oversight and with our audit and review to ensure that our policies, which are based on evidence and best international practice, are pursued and that the investigations are done in such a way that the root causes are found, addressed and subjected to recommendations. We pursue this process in all instances.