Mr. Dean Sullivan:

No, that is absolutely not what I am saying. I refer back to the comments the director general made earlier and what he meant when he spoke about the challenge of one person trying to do things with the structures that exist within the HSE at present. What I am saying is that at the centre, one is trying to run effectively 17 provider organisations, and a health business service, and a screening service - and, and, and. This is not a model that is set up to be particularly effective. It is just too broad a scope. The point I was making is that one needs layers to all of this. There is a level of scrutiny that clinical teams within the maternity networks that are putting it in place will have, really drilling down into the detail and the things that will set off warning bells for them. The further up, the more we rely on the cascading upwards of issues and learning. That is the point I was making, not that there cannot be appropriate flags and signals. What we cannot do right at the very top of the organisation is have all of that coming in because we would drown and it would just be a lot of noise. It must then be pushed into the system in order that the professionals on the front line, supported by managers, look at these data on an ongoing basis.