Dr. Tony Holohan:

Dr. McKenna is correct that in recent years there has been an increasing attention and focus on maternity services and there have been several publicly reported incidents, including some which related to delays or potential delays in diagnosis and appreciation of risk and so on before appropriate interventions could take place. The measures that have been put in place in recent years, some of which were identified earlier in this meeting, do not allow us to say we responded fully to everything that required a response. However, there are several maternity strategy information systems in place. There is a national mechanism through the centre for perinatal medicine in Cork and another through the national perinatal reporting system at a national level that gives us the ability to track and monitor relevant events. The Irish maternity early warning system, IMEWS, which is a reporting system in regard to obstetric units, facilitates a monthly reporting arrangement. As I said, patient safety statements are published. All of those measures are geared towards increasing the transparency of activity and the awareness of risk in the environments in which obstetric practice takes place, with a view to increasing the speed of response. The delivery of health care is not a risk-free enterprise. None of the science, people or processes involved are perfect but we have to constantly ensure the systems are capable of learning from and responding to incidents and applying the benefits of that learning. The delivery of maternity services is an area in which significant improvements are taking place, but none of the witnesses present would say that all of the risks that might exist has been fully and adequately eliminated. That almost never arises in the context of medical practice.