Ms Róisín Molloy:

Yes. On the national issue, the HSE is a huge organisation. In terms of ensuring that human error is not repeated and can be prevented happening again, there is an audit structure, a department, risk management, an advocacy department and a complaints department, which are very well-funded and resourced. They have the policies and had they followed their own policies Mark and Mary Kate would not have died. They failed in their duty to do the job that they were paid to do. They were to undertake audits but audits did not happen in Portlaoise hospital in terms of CTG trace readings. They did not investigate the baby's death. When Mark died they went so far as to ask us: "Do you want us to investigate this? Do you want to be interviewed?"

We met the advocacy team. In one particular conversation with the national director of advocacy, and he was extremely difficult to deal with, he said to me: "Now Mrs. Molloy, you have had your say and you are very good at this, now I will have mine." We were up against the system. They had every legal advice. Every time we sent an e-mail, we got a reply stating: "We are seeking legal advice on this." We felt that pressure. The HSE had a responsibility. It had known. It had a complaints department. Every single one of the parents we met and to whom we have spoken in the past number of years has said that they tried to raise concerns, even down to the basics of: "What happened? Why did my child die? Why was he injured? Why was I left with severe injuries?" Each and every time their complaints were not listened to and they were not logged. There was no sense of getting a pattern here to see can we learn from this. The information was there and they chose for whatever reason not to act on it. That is something that we hope the committee will be able to ask the HSE today. The HSE does have a responsibility.