Dr. Philip Crowley:

We have been training people over the past six to eight months.

To really change the culture to one of open disclosure, we recognise the need to carry out a phenomenal effort in training people. Two people were involved in that - that is the number of people implementing the policy. We are now training trainers to see if we can drive it home, follow it up and ensure it truly becomes embedded. Any investigation from now on and any assessment of how people are dealt with will be done in the light of whether the open disclosure policy, which is clearly communicated to everybody, was properly followed.

Maybe I should come to the investigations now. The time lapse in investigations is another thing that impedes anybody achieving any sense of answers or closure. Historically our investigations have taken too long. There are a number of reasons for this. One would be the difficulty in accessing experts, particularly in the area of maternity. We have heard of the shortages we have in the maternity services. We have had a significant number of demands to seek expertise to facilitate comprehensive investigations and that has caused delays.