Ms Mary Dunnion:

Yes. There were many factors. One must consider whether the staff are familiar with and confident in the processes that are in place. That is true for any organisation, including HIQA. If there is confidence in the system, is it being adhered to? If it is not - we are all human - is that non-adherence detected and managed and the learning shared? We found significant opportunities for improvement in Tusla in that regard.