Mr. Jim Breslin:

That is an important aspect of it. We have put in place the National Patient Safety Office. We have a surveillance programme and a legislative programme. The committee will be aware from our previous engagements of the legislation that is under way in this area. The HSE has put in place a quality and patient safety directorate. There is very much a focus on this at the provider level. Mr. Connaghan has spoken about the serious incident management protocol, which started with maternity hospitals publishing monthly patient safety statements that set out the levels of safety within our hospitals and explain how the risks that exist are managed. All hospitals are now doing that. There is lots of learning.

I would like to mention another learning from the blood service. There is a need for patient involvement and patient advocacy. I have spoken about how the haemophilia and hepatitis C community has come into the design of the service. That is a critical aspect of how we need to operate as a health service in general. In the coming weeks, we will award a national patient advocacy service. When something goes wrong, people lose trust in the health service and need someone to work with them to find answers to their questions. We are going to put in a national patient advocacy service involving skilled people who understand the health service, but are not employees of it, to work with people in such circumstances. I am not telling the committee that we have cracked patient safety in Ireland. It has not been cracked in any healthcare system. We have to work each day to try to improve this. We also have to improve our processes for mediation and engaging with people when things go wrong. I was in Northern Ireland three or four weeks ago for a conference with colleagues there. They spent €117 million on medical negligence and they have every single issue we have here. We are going to work together on those issues. Dr. Henry has spoken about the work that has been done in England, particularly with regard to mediation. We can learn from others. We have done a lot in this space.