Dr. Tony Holohan:

No. That is not the conclusion I would have taken from it. The reference to the State Claims Agency was the extension of the implementation of the national incident management system to the screening service. That has been in roll-out for a number of years, and the extension of that right across the clinical system still has not been fully completed but it is very significantly advanced. It is a prerequisite to being able to record incidents. What we need to be able to move to then, as we strengthen our implementation around open disclosure, is that system capturing the fact of open disclosure when adverse events have occurred. In dealing with adverse events, it is important to point out that the open disclosure policy relates to adverse events and it is correct to say that not every false negative is necessarily an adverse event. Some judgment is required on that and the letters provide those flexibilities. Those are templates that have to provide for any eventuality. Any individual letter that will issue in respect of an individual patient will look specific to that patient and I would have known that.