Mr. Patrick Lynch:

A range of things happen anywhere in the health service on any given day. Therefore, when one asks about alerts, one should note there is a whole range of alerts and different levels of severity. Certainly, where patient safety is any way concerned, we have incident-reporting systems and risk-management systems, all of which should ensure the people who need to know do know. That is not just for information purposes because very often some action has to be taken.

In the context of the serious incident management team, our objective, as I said at the beginning, related to the women concerned. We did not know last Friday about the 208 women and how many had been told and how many had not. At the end of the weekend exercise, we were surprised by the number who had not been told. That, for us, was very concerning in terms of openness to the women. We have not got to the why, who and what at this stage but I believe there was an important lesson to be learned. It might not have appeared on an incident system but there are opportunities for any part of our service now to know that there are certain things that have got to be escalated, not just to notify people but very often with a view to taking action, and something has got to change as a result. The work we have done in the past week will help in addressing this.