Martin Daly (Roscommon-Galway, Fianna Fail)

I will come back to the reporting system. It is clear from the 2021 internal report from CHI, which Mr. Gloster did not know about, that there was a breakdown. There did not seem to be a view within CHI management that the report should have been progressed to the HSE. That points to a gap in governance. That is a question the public really wants to know about. Can something that is, on the face of it, so egregious, be internalised, not just in terms of the governance around the NTPF but also the culture in that particular hospital? We still do not know what hospital it was. There is a suggestion that report will never be published for various reasons. How do we learn from that? How do we change things if we cannot get there?