Mr. John Gleeson:

We were issuing communications to treating clinicians under the open disclosure policy of the HSE, which applied throughout the organisation. We made the assumption that as we passed the information down the line the clinicians would pass it on. We alluded, in the previous meeting, to the fact that we did not check that they had done so, and that was an error in closing out the communication trail. We did, however, make the assumption that the policy was in operation and was working throughout the various sections of the organisation.