Mr. Seamus McCarthy:

One core element of a governance structure is a risk management capacity in an organisation. What a risk management capacity should do is identify those types of issues, the learning points and ensure that there is follow up and that any continuing exposure is dealt with. There should be some kind of oversight in an organisation of where things might have gone wrong, have lessons been learned and if changes have been implemented. That might be the area on which to focus when addressing Saolta, and to ask if Saolta does not have the information, what is its risk management function doing if it is not doing that.