Mr. Peter Tyndall:

There are a great many question and I will let Ms McNally answer some of them.

I thank the Senator for his range of questions, some of which point to the way forward. There is no question but that we will be producing more themed reports. It is a good way of generalising what has been learned. It sits alongside the casebook, the first of which is due to be brought out in the autumn. The question is how do we ensure we do not keep repeating the same mistakes. There is no question in my mind that staff in the health service are working under extreme pressure. People will say they are struggling to find time to do the job well. That said, the issues around palliative care and so are non-negotiable. Should people be in pain because staff are too busy? Should they not have access to adequate food and water? Should they not be treated with dignity and respect?

Ultimately, it is for me as Ombudsman to say that regardless of whether these things were caused - as they may have been in a small number of instances - by resource pressures, much of the time they are caused by the failure of leadership to create positive cultures around care. I will continue to highlight them. In a sense, there is a line over which one must not stray. Whether an issue arises because of resource pressures, individual failure of leadership and management or a failure of training it is still for me to highlight it. Ms McNally will speak to the committee about trends and compliance.