Ms Breda Kerans:

Could I add one point? You asked what we could do, Chairman. One thing I think is very important that we are not doing, which is happening in many other jurisdictions, is capturing the service user experience in a meaningful manner. We have ad hocpatient satisfaction surveys, which are a very different thing. It is happening in countries such as Canada and the UK and we have linked various surveys and how they happen in our document. They are particularly good examples. The reason I feel that is very important from a safety aspect is that service users navigate the entire service from beginning to end. Dr. Lynch mentioned that earlier. I am a founding members of AIMS Ireland and we founded the organisation ten years ago. One of the things we found at the outset was that women were highlighting issues to us that we were not hearing from maternity units as being a factor, yet when we had the tragedies and they were investigated the issues women highlighted to us were seen to be causative factors. Capturing the service user experience can highlight problems at an earlier phase and that is a very important part of developing a safer service.