Dr. Tony Holohan:

He was not told because the information we had was information about the process of implementation of arrangements to feedback findings from the clinical audit to patients. The updates we had from the HSE were updates that gave us assurance that the process was taking place over a number of months and that the HSE was problem-solving when issues arose to get through them. It completed that process around late summer or so in 2016. I am aware that a clinical audit of that nature is not a common thing in screening programmes internationally. That is a positive development. I knew that open disclosure arrangements in respect of those findings would be even less common. These are features that would have added to the value and the standing of our screening programme in international terms and we saw them as good developments. There was nothing in that in a broad sense of risk, problem or concern being escalated to us as part of all of that which would be the subject of disclosure. That was the information we had at the time. Clearly there were gaps in the system.

It is very clear to see in retrospect that if the arrangement had been in place to have absolute clarity tied down before the commencement of feeding back of those findings with regard to whose job it was, what precisely was going to be fed back by way of a clear open disclosure policy for the service and a clear feedback loop to tell the centre, in this case the screening programme, then this might not have happened. There is clear learning in respect of all of those things. Without getting ahead of where Dr. Scally will take us in terms of findings, at a minimum we can see these are developments that will enhance the screening programmes. The patient safety Bill, which the Minister brought to Cabinet last week, will give the Minister powers to essentially set guidelines for clinical audit that would ensure that when clinical audits are started - of this nature or elsewhere - that in advance of commencement those guidelines would be crystal clear on the question of responsibility for feedback to patients and on the question of feedback to the centre so there is verification the open disclosure has happened.