Mr. Patrick Lynch:

I know people do not like the idea of systems or systems failure but I have seen many review reports where a clinician is only the final point in a weak chain. They are the ones dealing with patients face-to-face but a whole series of things will have gone wrong before that point. As well as the joint senior governance forum between us and the State Claims Agency, we now have a senior clinical risk forum between the clinical indemnity scheme in the State Claims Agency and senior management in the HSE. We meet quarterly to look primarily at clinical risk. It is an opportunity for the State Claims Agency to escalate concerns it has raised locally to a national level. Its risk advisers deal with local hospitals but if it is concerned that issues are not being addressed or are not adequately responded to, there is a forum, quite apart from the interactions we have on a day-to-day basis, at which it can escalate those issues. Equally, if we see emerging risks, which the State Claims Agency as the indemnifier will need to know about, there is a formal forum for that. Again, the State Claims Agency may want to comment on that.