Mr. John Connaghan:

We also need to describe in that response what the most basic level of feedback is with regard to cases. My experience is there is regular case review particularly where there are adverse cases in a multidisciplinary team. There are arrangements where one looks back, discusses the case and decides whether or not the action taken was appropriate. What we probably need to do is start at that most basic level because if we get it right there it solves problems for later on as well as going up a ladder.