Mr. John Gleeson:

It is clear from Mr. Connaghan's statement that there was a failure to continue the communication from the treating clinician to the woman. The failure was not to have any responsibility assigned. That was the failing in the system. It did not continue the loop. Had I assumed or been assigned responsibility for it, then it could have been done. I have already apologised for that link not being made. I reiterate that apology now. We have to learn from this process and make sure that final step is taken and if it is assigned to me I will be more than happy to ensure it happens.