Dr. Allan Goldman:

I thank the Deputy for his question. During the months around October, after the patient very sadly passed away, we were seeing many complications and returns to theatre. At the end of September we had paused the complex surgery and were having ongoing discussions with our multi-professional team. I was meeting with the clinical directors, CDs, anaesthetic teams, ICU teams, neurodisability teams and nursing teams. It became apparent from their concerns, especially with regard to the infection rates, returns to theatre and, in particular, the metal work, that we needed to do something. We all sat in a meeting-----