Ms Lucy Nugent:

One of the challenges we previously had was that we did not have centralised procurement. In Temple Street particularly, where this incident happened, there were several different departments that could directly order things. In that situation, the items was ordered through the clinical engineering department, although as well articulated in the HIQA report, the individual was unaware of what they were being procured for. The individual thought they were part of an external traction system. What we have done since January 2023 is to have centralised procurement across all of CHI.

Regarding the non-procurement-----