Dr. Philip Crowley:

Obviously, there has been a lot of publicity about this case and there have been two reports, as well as one inquest. As for how we have managed it to this point, it is in contrast to how the death of Tania McCabe was managed, as that was dealt with as a local incident and managed locally. The report was available but was not implemented on a national basis. In recent years, the HSE has established a number of processes to ensure this is not the case with reports of this nature. We have a process agreed between myself and the line division under which we will consider jointly any report that is published into safety of care. Moreover, we will establish a committee in advance of the report arriving in order that it is ready to receive the report, and this is what has been done in respect of our own report into the care of Savita Halappanavar. That same group that is being established with expert input and now under the leadership of Ian Carter will be asked to implement our own report and its implications, the coroner's inquest findings and now the HIQA report. It is important to state that the recommendations that pertain to Galway will be implemented in all units and, most importantly, some of the key priorities already have been advanced, some to implementation. In particular, the Irish maternity early warning score has been implemented in all 19 units. Training is being done in all 19 units and patient information leaflets are being developed for patients in order that they understand the process. I believe we are the first State internationally to have a nationally agreed and implemented maternity early warning score, which is quite different from other adult early warning scores. There are sepsis guidelines, and there were sepsis guidelines in Galway at the time, but they were not properly followed. We need to urgently develop national sepsis guidelines and have in place a group that is tasked with developing those. We will ascertain what kind of resources they now need both to develop guidelines and to develop them to a level and standard that will pass the scrutiny of the national clinical effectiveness committee to which the Minister referred earlier and get the ministerial mandate this will entail.