Ms Eilísh Hardiman:

If I may, I am focusing on patient safety and the risk elements because they were our priorities, keeping the patients to the fore in our minds. The issue raised in relation to the risk was around what we would call a single point of failure, where there was a single clinician involved in a tertiary service. That was brought up through the appropriate elements of the HSE. Thankfully, the HSE totally supported us with investment very early in 2021, even before the report was finalised. There were issues and matters coming up through our processes that were not just being revealed in this report, but were being managed. Most important were some of the HR processes. They were historical and had been there for years. They were addressed as well.

We took the training issue very seriously and went with the training bodies and the external review of how training was assessed. We were very open about all of those aspects that were addressed in 2021. The staff felt - we wanted them to be open and honest - that these were long-standing issues and they wanted them brought to our attention. I am glad they did that. We said very clearly at the time that if they raised a matter, we would take action and address it. Action was absolutely taken. We reported specific issues through the HSE via the relevant processes and our normal processes, but we did not disclose the report, and Miss Nugent has outlined why.