Alan Kelly (Tipperary, Labour) | Oireachtas source

I quote: "In cases where the woman has died, simply ensure the result is recorded in the woman's notes." Does Dr. O'Keeffe believe that was okay, and that it was ethical?

Second, on the real issue here, Dr. O'Keeffe was in charge of this area. Subsequently, I understand her position changed and it was no longer part of her area. Mr. Connaghan might tell us why that happened. The letters went out to clinicians in June 2016. What I do not understand is why they were not also sent to the hospital managers, which I would know now if the Department of Health actually did its job and told me the answer?

That is why I want to make up this jigsaw. Why were the letters not sent to the hospital managers? Second, why did Dr. O'Keeffe, in her role, not follow up to understand why these women, who were so badly affected, had not been told?