Mr. Tony O'Brien:

There was a common theme running through the questions posed by members in respect of the thought process we employed. We have to recognise collectively that all of the things we have had in place - as a system - did not achieve the desired result at Áras Attracta. As Deputy Billy Kelleher indicated, it is true the HSE has a somewhat patchy record in terms of the implementation of HIQA reports. However, that is not the case in respect of Áras Attracta. All of the recommendations were being implemented, yet there is clear evidence from the video shot - over 200 hours of filming was undertaken - of what happened in bungalow 3. The central question that arises relates to the additional steps we need to take, but I do not think it is an issue of HIQA being in some way defective. Regulation can only take us so far. Cultural change is required in the context of some of the other actions we need to take. There is a realisation that, regardless of whether it is in a community or non-congregated setting, in a place such as bungalow 3 or a private home, once the doors are closed, we cannot see what the particular subset of people behind them are doing.

This is what RTE, in its efforts, has demonstrated to us and is one of the reasons we are focusing very strongly on empowering whistleblowing in the health service and making it easier for people who have concerns. We saw in the film that some people did not appear to be taking part directly in any of the abusive practices, but did not appear to be doing anything to stop them. We want to empower these individuals to blow the whistle more easily.
We also intend, as I have mentioned elsewhere, to undertake undercover investigations using the same techniques as RTE. We have also published a European prior information notice, which is part of the procurement process, to seek the specialist advice and services we would require for the use of CCTV in vulnerable care settings on an overt basis, that is in an open and transparent manner, but also, where there may be a prima faciecase for doing so subject to us being able to make this legal, decent and honourable, also using on occasion covert filming in various settings. It is apparent that the measures one would have expected to have an appropriate outcome did not have the desired outcome in this instance. There is no basis upon which we can assume this is an isolated incident. We need to provide assurance throughout the sector, and this was essentially the focus of today's summit with all of the providers, regulators and other groups.
Mr. Healy will address some of the specifics with regard to what we are doing at present, and Dr. Crowley was asked a specific question which he will answer. There is a realisation that the measures we put in place which we believed would be sufficient are not, and therefore we must do more and do things in different ways. I do not say this in any sense to be critical of the role of the regulator in this instance. Regulators can only do so much. HIQA has been discharging its responsibilities in line with its legislation and procedures.