Dr. Sam Coulter-Smith:

I will address Deputy Ó Caoláin's questions first. Adverse outcomes are tragic. They are of huge concern to us when they happen. They are obviously major life events for all the people involved. They are very difficult and very time consuming. In addition to the grief there is often anger and many issues need to be dealt with. The key to dealing with adverse outcomes is to keep lines of communications open, to embrace the idea of open disclosure, and to have a bereavement team that is able to come and sweep up the situation and get everything organised so that no issues are left unsorted. There needs to be open disclosure and an open door policy so that people can communicate and those lines of communication need to be with senior clinicians and senior midwives. That is why Dr. Sheehan mentioned the idea of a lead person involved in everybody's care.

We also need to have perinatal pathology. Our submissions mentioned that perinatal pathology is not available everywhere. That is a very important part of the jigsaw for patients. Timely post-mortem examination with timely results keeping those lines of communication open with patients is a really big part of successfully dealing with an adverse outcome.

The coroners' system is slow. Getting information back from coroners can often take months. The more time that is left before making contact with patients and getting them back to give them results is time for them to dwell on what has happened. We need to keep those lines of communication open in the intervening time and we need that process to be as speedy as it can possibly be.

I have not personally got involved in external reviews; I am far too busy doing what I do on a daily basis to do that.

Often, such reviews are done by senior clinicians who filled my role previously, that is, ex-masters of the maternity hospitals. Success in dealing with an adverse outcome lies with communication, bereavement teams, perinatal pathology and open disclosure. We in the Rotunda have embraced this approach completely. We are open with patients when things go wrong. There will always be situations that are difficult to deal with but, in the majority of those, patients are grateful when one is open and honest with them.