Dr. Sam Coulter-Smith:

I am not sure. It may be pressure of work, it may just be that the system is a little slow. It would assist us greatly if those types of cases could be turned around more quickly. We have a good relationship with our coroner. We are able to lift the telephone and talk. If we need to give results to patients, he is often amenable to doing so. This may not be the case across the country. I do not know.

Regarding Deputy Kelleher's question, we often have knee-jerk reactions to adverse events. This is unfortunate, as we need a considered approach. It revolves around the same issue I raised in my answer to Deputy Ó Caoláin. The cornerstone of good governance is open lines of communication and open disclosure, but we also need other elements. The cornerstone of good obstetric care is the staffing level. This must be appropriate for our activity levels. We must also have an appropriate infrastructure. One cannot put 40 deliveries per day through nine delivery rooms. It would not work and would be too much strain on staff. Staffing, facilities and infrastructure have been stretched significantly in recent years. Funding of the service is also important. Maternity services have been underfunded compared with the level of activity in the system. These four elements will be important in the development of our service.

As to where should be look for best practice, there are good models across the world, for example, in elements of what Australia and Canada do. However, one cannot just transplant a system from one health service into another because one is not comparing like with like or starting with a blank canvas. One should take the good elements and consider what is available. Plenty evidence of best practice has been published. We have discussed reports, for example, Hanley in 2003, KPMG in 2008 and the recent report on manpower. They are all saying exactly the same thing, namely, that we do not have enough midwives and doctors in the systems. We must rectify that situation.

This brings me to Senator Colm Burke's question on how to ensure that we bring more people back to the system. We must be competitive in the package that we offer. It is not just about salary, but services, operating theatre lists and the ability to practise what people have learned abroad. Deputy Catherine Byrne asked about the culture of people travelling abroad to train. I did that, as do the majority of people. One qualifies as a doctor, decides what one wants to do, does a year or two in Ireland and learns the basics before going away, subspecialising and becoming skilled in a particular area. Previously, people used to want to return. Nowadays, that is not the case. We have well-qualified doctors. Some of the best in the world come from Ireland. Unfortunately, they are not returning anymore. This boils down to the package that we can offer, including facilities, infrastructure, staffing and funding levels and the possibility of performing the sort of world-class research that we are capable of but which we cannot do currently because we are not bringing people back to do it.

The answer to all of these questions is that, when bad things happen, be open about them. There must be open lines of communication, open disclosure, bereavement teams and pathology. A multidisciplinary package is required to answer questions quickly, openly and honestly. The same applies in respect of the quality of the service. It all boils down to facilities, infrastructure, staffing and funding.

As to the figure of 4,000 to 5,000 births annually per delivery unit, I am not suggesting that units that deliver 1,500 or 2,000 women should close. Rather, if one wants a delivery unit that can provide a medical model of care - I do not like talking about medical models - including the full range of anaesthesia, perinatal pathology, 20-week anatomy scans and foetal medicine and newborn babies looked after by neonatalogists, not paediatricians, one needs a critical mass of approximately 4,000 or 5,000 deliveries in order to ensure that those people have enough work to maintain their skills. One will not get value for money from a smaller unit because, although teams will be on call and available, they will not be doing much with their time. If a unit with 1,000 deliveries has a full team of obstetric anaesthetists, they will not be doing a great deal for much of the time. I am not sure whether I have answered the Deputy's question.