Professor Gerard Bury:

I do not for a second want to reflect on the management of those tragedies by either the medical, Garda or coronial services. They do all that is appropriate within the current framework but I refer the Chairman to the relatively recently implemented Health Service Executive, HSE, serious adverse event policy, which has introduced a culture of learning, risk reduction and quality improvement at all levels within the HSE and has specifically constructed root cause analysis teams to explore certain types of serious events, including deaths, that occur in the State's care. My point is that methadone is provided purely in this State on the basis of a contract between the State and a doctor and the patient.

If a death occurs involving methadone or involving attendance at a drug treatment centre, it seems to me that it should be managed in exactly the same way as the policy applies to all other deaths of people in mental health care services. It is an additional layer, not a reflection on the current provision of care. There is learning to be had at a clinical level from the investigation of those events.