Dr. Stephanie O'Keeffe:

It would appear that there was a failure in detecting the risk from concerns being raised and what that would mean for patients. I say that, having looked at all of the information that I have now. There was also a failure in escalating real evidence of risk as a result of the communications that I have seen. At the time in 2016, the audit would have been seen as a control measure and the risk pieces would not have changed throughout that.