Mr. Tony O'Brien:

A systemic failure would tend to relate to the whole of the entity in question, meaning the whole wide HSE. In this instance, we are talking about a particular decision to communicate the results of an audit in the part of the organisation that is known as CervicalCheck where the decision was made but, as we now know, it did not result in the communication that was expected. There was not a loop in place to establish that the communication had occurred. At the time when the serious incident management team began its work, it was the expectation of those in CervicalCheck that every woman had been informed. Consequently, when we discovered it was only 48 out of 209, it came as a very significant-----