Dr. Colm Henry:

There were triggers and we have a system in place. The statements Deputy Burke referred to are not the only system we have to ensure safety. We have an obstetric-event support team which goes into all maternity units following a number of triggering events, including therapeutic hypothermia, to help assess any early learning from the incident, how the incident should be investigated and what learning should be applied to other units. It was the concerns from the clinical director in the unit, from the number of cases of therapeutic hypothermia and from the intervention of that external team that led to the external team being put in place in January of this year.