Dr. Austin O'Carroll:

I thank the Senator. There are three key elements to the learning system. The first is the five-yearly reports, which will be reviewed by a multi-agency panel to try to ensure any recommendations are reviewed and put into action.

The second one is the critical incident analysis, as we described, to ensure that we learn from individual deaths. The third one, to which we also alluded, was the rapid review of clusters of deaths. Having those three elements would provide a significant learning system. We must also ensure that the learning derived is put into place. As was mentioned, there is no point in having reports and recommendations gathering dust. Therefore, part of a learning system involves reviewing and ensuring the effective use of existing learning. As we said, there is nothing new in this report. It has sometimes mentioned things previously recommended. We must ensure that is part of the learning cycle as well.