Ms Cliona Cassidy:

It depends on the number of incidents. We operate on an on-call basis. In 2016 there were 15 incidents, of which nine involved fatalities. In 2017 there were five incidents on which we began reports and of which six involved fatalities. Our automatic reaction is to begin an investigation. There were one or two investigations that we commenced on a preliminary basis and it appeared that the fatalities had been due to natural causes. In such circumstances it is not appropriate for us to make safety recommendations or we would not be in a position to do so.