Ms Yvonne O'Neill:

One of the things from which we were getting assurance in the context of the report and the review that was done by the commission was the number of cases they brought to our attention relative to the total number of cases. That was giving us some assurance that the more widespread practice is that cases are reviewed across the teams.

That review process will always give us learning but the reassurance is that the overall case numbers were small - not that any number is never not serious - on foot of the Mental Health Commission's interim report.