Dr. Tony Holohan:

In a general sense we had many examples of patient safety issues that arose over the years that would have identified that open disclosure was not happening effectively both before the introduction of the policy and afterwards. We were involved in some ourselves and I can give some examples including Portlaoise, where the baby deaths occurred. There was not just not open disclosure, there was active withholding of information from patients. At the same time and concurrent with the time period of this particular audit, a colonoscopy review was taking place arising from Wexford, where open disclosure was an escalation issue and a concern that was being raised on a continuing basis by the Department.