Dr. Tony Holohan:

In hindsight, I understand that. I am very happy to hear what Dr. Scally may or may not have to say on that particular question. We saw the escalation and the decision for escalation on its own merits as something worthwhile in broad terms. Not everything that I would be aware of either in terms of positive developments or, dare I say, in terms of negative developments in the system would be things I would see as necessary to escalate to the Minister. We operate on the basis that as much as we can we try to manage and resolve issues if they are things we can manage and resolve and we have a system for that. I will not tell the Deputy it is a perfect system. I will and would like to say it is a system that is getting better and better. For example, we have a patient safety protocol that has been in development and improvement between us and the HSE which captures the kind of information we really need to have when patient safety incidents arise so we are able to discriminate between those circumstances that we really need to be concerned about and where, as the Secretary General said earlier, we need to step in. There was evidence of that at the time. There were areas where we were stepping in with regard to other areas. In respect of this particular one, I understand the Deputy's question. We did not at the time see it as anything beyond positive developments by international standards. We were getting the assurances from the HSE around its implementation of that but I am very happy to hear what Dr. Scally has to say about it.