Mr. Ciarán Breen:

I thank the Deputy. She is right, the SCA has a clinical risk management role with all of the services and hospitals. This issue was not known to us. How could we have found out about it? We did visit the CervicalCheck screening service at the time. I indicated that it was in March 2017. The problem with notifying women did not come up. We only got to know about this for the first time after the Vicky Phelan case, as I told the committee previously. To give the Deputy some reassurance, in the meantime we have visited all of the screening services to pick up all of these topics about disclosure and about notifying matters to us and making sure that these things are being put up on the national incident management system, NIMS. That was one of the issues we had with CervicalCheck. It was not putting the incidents up at the time. I assure the Deputy that we have addressed these issues with the screening services, most recently in the last two months, and we will continue to do so. That is one of the lessons learned.