Ms Bernadette Ryan:

I take the Deputy's point that when something goes wrong in health care it is rarely one person's fault and it may be due to a combination of factors and a system failure. Dr. Kathleen MacLellan would probably have further thoughts on this. We are moving to a situation where it is incremental and we will get there, but it is taking longer than anybody would want.

To return to the Deputy's first point on open disclosure and consistency, I know he made another point about open disclosure but on the element of consistency in the context of what is in the health information and patient safety Bill, originally it was part of that Bill and it was taken out to progress it faster. As he will have noted, this Bill is quite a large one dealing with a range of issues. We were aware that we needed to keep things consistent as far as possible because open disclosure was part of the same package as the external notifications to authorities of an incident.

On the Deputy's point regarding accountability, as we are moving forward towards licensing, clearly, a worse case scenario for a health care provider would be that the licence would be jeopardised. That probably brings people's attention very quickly and closely to the need to react and put in place proper practices. Dr. MacLellan might wish to respond to the Deputy's other questions.