Dr. Philip Crowley:

That is the case in almost all of the delays. Another issue in regard to the delays - the Deputy raised it - is the availability of trained investigators. What the Deputy proposed was to have full-time investigators. That would be one approach. However, we do not know where an incident will occur and we wish to have people trained across the entire health system. We have trained in the region of 800 people - 400 managers and 400 staff - to understand how to investigate something properly. In 2014, we instituted a new policy that was strongly influenced by my interactions with one of the families present and others. It puts a clear timeline on investigations. They should be completed within four months. This may seem like a long time, but it is a challenging timeline because we must source investigators and experts and ensure that due process is adhered to. This work often delays investigations.