Dr. Maura Young:

I will try to answer that. The Deputy's point is that, in this case, our measures for picking up deviations from practice did not work. That is clear because it went on for four to five years. We have our standard governance lines, such as in an acute hospital system, as Dr. Burke was explaining. It goes up the CAMHS clinical director and then to the executive clinical director, ECD, eventually. However, what happened was that we were looking at our key performance indicators but our quality measures were not robust enough to capture the quality of the service provided. We were able to capture how long people were waiting and the length of time for the referral, but we were not able to capture the quality of the service that was provided on the ground. We realise we need to do a lot of work to improve how we measure the quality of service, and a big component of that is service-user feedback.