Dr. Austin O'Carroll:

Critical incident analysis exists in medicine. It would be similar to a safeguarding review. The key features are about becoming a learning organisation and trying to learn from what happen to improve. A key feature is you have to do it in a non-blame culture. Obviously, if someone has stepped way outside his or her brief and acted totally unprofessionally, you cannot defend that, but what often happens, especially when there are deaths, is you get an outburst in the media and people return to a defensive position. The critical incident analysis is where you say to people this is not about blame, it is about learning and improving services.

There are processes already. The HSE has similar processes for critical incident analysis as part of its quality and safety element. It would just be a question of applying those systems. What would happen is that once a death occurred, you would review the death. It is called a desktop analysis. If this was someone who was dying of cancer, it is an expected death and you do not need to do critical incident analysis. If it is someone who died of an overdose in the park, let us do a critical incident analysis. You would then approach all agencies that have been in touch with that person. It could be the homeless, outreach and drug services but it also could include the police, courts and prisons. You look at all services and ask what we could have done.

You could find out that the person who had an overdose had an intervention with the Garda. You could ask whether the Garda could do something about looking at whether this person should have been on methadone. That is the type of thing you would do to learn whether this could have been prevented. You need to do it in a non-blame analysis in order that people are open and you can get all the information to find out what exactly happened and identify where you could have intervened to potentially have prevented that death. Does that answer the Deputy's question?