Mr. Jim Breslin:

Implementation. Across the board, all countries are moving increasingly towards the type of relationship that Bill Prasifka outlined as the model that we want to implement. Change does take some time to embed within a professional organisation. The policy that has been there since 2013, and evidence was given last week on some audits about how well it has been implemented, has made significant difference to how doctors and clinicians approach patients, but we have not got it 100% there and there is a lot of work still to do. The work that was done in last year's civil liability Bill was to create the type of supportive environment for everybody involved in that disclosure to feel that they could do it without a consequence for doing it, to be able to admit, say what went wrong and deal with the consequence of that, but without the very act of telling somebody being used against them. That was an important thing to address what is a fear among the medical profession in different countries, which is a medico-legal fear that something will subsequently come against them in terms of their professional legal standing. We dealt with that last year.

The next bit that we are going to deal with is in respect of serious events, because there are a range of issues that arise within the health services which are routine, which do not involve harm, but which are sufficient in terms of being an incident to require attention for the future. In respect of serious incidents, we will now have a position in place where it is mandatory and it is required under law that that happen. That will be a further step forward in making sure that, in cases such as this, it does happen.