Mr. Peter Tyndall:

In each of the complaints we would have taken it through to a conclusion which would have involved specific recommendations. Because they were generally dealt with at examination stage, the recommendations would have been agreed to. This was not instead of giving individuals the redress they wanted, but very many of them came to the office, saying their primary motivation was to ensure that what they had experienced would not be experienced by anyone else. In a sense, what we have done is deal with the second stage; we have not just resolved the issue with the individual hospital but also tried to drive the learning more widely across health services.