Mr. Tony O'Brien:

Every case that results in significant harm to any individual is regrettable and a tragedy for that individual and his or her family. The State Claims Agency operates in the wider public interest in the way that it approaches claims and in its efforts to bring down the overall cost to the taxpayer of meeting these liabilities as they arise. Some of the claims referenced by the Deputy are, by their nature, aged because they have resulted in court proceedings over a number of years. The point of learning is actually much closer to the adverse event than the issue of settlement. One of those cases mentioned by the Deputy goes back to 2004. In each instance of an adverse clinical event an appropriate review is carried out, under the auspices of either the local or national incident team, depending on the seriousness of that event. Through a clinical governance process, led by a director of quality and patient safety, the HSE ensures that the maximum learning is derived as near as possible to the time of the adverse event rather than waiting until later on. The risk management process is very much focused on learning from these events as they arise. The Deputy has instanced a case where there were clear opportunities for learning at that time. While the overall settlement issue is something that is kept under review, the focus of learning is much earlier.