Dr. Stephanie O'Keeffe:

At one-to-one meetings, I would have a management report. We would also have a performance review meeting every month and a senior management team meeting every month. Typically, in those processes, there is a requirement of the senior management team to escalate any new or emerging risks, obviously within the risk register, to be able to detail them comprehensively and at a one-to-one meeting to brief me on anything that may be rising in any of the programmes across the NSS. Within all of those management reports, it states that the audit process was going well.

Given what has happened and given the fact that actually the communication to women happened in the context of a national controversy where people are worried could it be them or husbands whose wives have died are concerned, that was not the intention. It was not escalated to me. I was not in a position to either resolve it and I was also not in a position to be able to communicate to my boss that it was a risk or, indeed, to communicate it to the Department of Health.