Dr. Stephanie O'Keeffe:

Yes. In the briefing note the Deputy has, from October 2016, it is made very clear that the process we were engaged in over the period had concluded and that the historical letters had been sent to consulting clinicians. It is very clear within the memo that the programme was engaging colposcopists with treating clinicians to support the process of open disclosure and that they would be issuing letters at a pace of approximately four to six every month as they started to conclude reviews that were coming in. At that point, they were also hearing about cases that were coming through, which was always the intent. In carrying out this audit process and in sharing this information with women, the reason they were flagging the media piece was because we always knew that, once women had information, they would have absolutely every right to seek legal advice and legal address if they so chose. Therefore, we were expecting cases to come through. What I was not expecting, and what we were all not expecting, was that women would not be told.

After October 2016, I received a management report every month from the screening service stating the audit process was going well and that improvements were being made to the programme. In about May, June or July — I have the specifics here if the committee needs them — it would have stated in the management reports that three cases were going to the State Claims Agency. That reinforced to me the view that the process was working. Looking back, I could ask if I should have relied on my one-to-one management team meetings, my senior management team meetings and bimonthly risk reports. None of those things told me-----