Official Report: Minutes of Evidence

The Chairperson (Mr Ross): I welcome Dr Paddy Woods, Deputy Chief Medical Officer; Fergal Bradley, director of the safety, quality and standards directorate; and David Best, head of the learning, litigation and service framework development branch in the Department. The session is being reported by Hansard and will be on the website in due course. In your own time, please brief us, and then I will open up the meeting to questions.

Dr Paddy Woods (Department of Health, Social Services and Public Safety): Thank you, Chair and members, for the opportunity to give evidence in relation to the Attorney General's proposed amendment to the 1959 Coroners Act. This evidence session is very timely, given that it comes on the back of the publication of the report by Sir Liam Donaldson on openness and transparency in the reporting of deaths and other matters. His report highlights the complexities surrounding the appropriate involvement of the coroner in investigating deaths. Sir Liam's report concludes that Northern Ireland is in line with international practice. It also concludes:

We in the Department have been working on a number of developments that we can discuss with the Committee, if you wish, and which we believe will contribute to such improvements. We do not, however, believe that the proposals put forward by the Attorney General will deliver any element of that improvement. We have concerns that, in practice, they would have the opposite effect.

I will give members a bit of context for health and social care in Northern Ireland, with which some will be more familiar than others. Over 78,000 people are employed in commissioning and delivering health and social care in Northern Ireland. Each year, there are over 1·5 million hospital attendances, more than 7,000 treatments at accident and emergency departments and about 500,000 in-patient or day-case admissions. In addition, over 100,000 patients and clients receive a range of health and social care provision daily. There are approximately 15,000 deaths in Northern Ireland each year, of which almost 7,000 occur in hospital.

The Department expects all health and social care organisations to provide information and documentation to any reasonable and adequately specified request that might help an individual or family to understand the facts and circumstances of any death, but we feel that this must be done in a manner that avoids unnecessary bureaucratic burden.

I will highlight how we believe the system, as proposed by the Attorney General, would operate in practice. Our analysis reflects what happens, at present, in response to requests from the Attorney General for information on individual cases. Although no single request will bring an organisation to a standstill, the impact is felt throughout the trust. The specific clinical aspects are usually concentrated on a small number of individual specialities and clinicians, but there are wider ramifications for and additional workload experienced by other executive, managerial and administrative staff.

First, of necessity, practice front-line clinicians and other staff are required to review documentation and records in order to identify the material relevant to each request and, as a consequence, are diverted from providing services to patients and clients.

I am aware of the Attorney General's evidence to the Committee that the requests will not place a burden on the health service. In our view, and on the basis of what has happened to date, that is open to question. His evidence to the Committee suggests that the powers to obtain information will not be used sparingly and, as a result, will significantly increase that burden.

Secondly, the open-ended nature of the proposed amendment will leave those receiving the requests unclear about which records are relevant and which are not. That, coupled with the knowledge that, being liable to a legal sanction, they may be subsequently judged to have withheld material considered relevant, places them in an invidious position. We are aware that trusts already struggle to understand what information they are supposed to provide in response to existing requests.

Thirdly, the trusts, to ensure that they comply lawfully with requests, are likely to take legal advice. Apart from the direct cost of that advice, trusts will incur costs in staff time, including that of clinical staff, through spending a proportion of their time consulting legal advisers.

Fourthly, issues will arise with regard to the impact that such requests will have on family members of the deceased. Who will have the responsibility of engaging with families? Will it be left to the Attorney General or will it fall to service personnel?

Finally, as happens at present, trusts will end up duplicating effort, providing information on the same cases separately and, sometimes, at the same time, to the both the coroner and Attorney General, as well as the other organisations that may have legitimate interests in deaths that occur in hospital. It is worth pointing out that a range of bodies has interests in deaths that occur in hospital settings. In addition to the coroner and the police, we at the Department may have legitimate interest. So, too, might the ombudsman; the Regulation and Quality Improvement Authority (RQIA); individual patients and families, of course; in certain instances, the Health and Safety Executive; legal representatives acting on the part of various judicial processes, including negligence cases and statutory inquiries; numerous professional regulatory bodies, such as the General Medical Council and the Nursing and Midwifery Council; and auditors of various complexions, both internal to the organisation and the likes of the Northern Ireland Audit Office. So there are significant demands within the health and social care system to provide information, quite legitimately and duly authorised, in connection with the deaths of patients and service users. That is in addition to any action that a trust itself might instigate in investigating a death.

The Attorney General, in evidence to the Committee as part of the consideration of these proposals, stated:

The evidence that we have at our disposal is that, overwhelmingly, deaths are reported appropriately in accordance with statutory requirements. We hope to be able to provide the Committee with more data on that in the coming weeks. We will also be happy to discuss, in general terms, the position of those cases in the Northern Trust that have been referred to in media coverage and in the Attorney General's evidence. As members will be aware, under section 7 of the Coroner's Act 1959, it is a statutory requirement for doctors and others to report a death to the coroner, together with the facts and circumstances relating to it, if it resulted directly or indirectly from any cause other than natural illness or disease for which the deceased had been treated within 28 days of death or in such circumstances as may require investigation. Not to do so is a criminal offence.

The coroner can already ask for all the information about a case, and the Attorney General can both direct the coroner to conduct an inquest and ask for sight of whatever material the coroner has considered in deciding whether to conduct an inquest. We are aware that the Attorney General has used those powers to that end. We are also aware that, in some cases, the Attorney General has directed the coroner to hold an inquest without seeking any further information, and, in others, he has directed an inquest before the coroner has concluded his investigations.

The proposed amendment enables the Attorney General to engage in those requests without having to demonstrate any rationale; without anyone having oversight of his actions; and without being required to provide any clarity on what information he is seeking. The onus and burden are, instead, placed on the providers of the information.

It would be useful at this juncture to clarify the background and purpose of the serious adverse incident (SAI) process. In order to be reported as a serious adverse incident, an incident must fall into one of a number of categories, one of which is the unexpected or unexplained death of a service user. Most serious adverse incidents do not involve death, but, when they do, there is not always a direct relationship between the incident and the event. An example of that, which currently stands, is that child death due to terminal illness is automatically reported as a serious adverse incident, even though there is no concern about the care and treatment provided. Whilst, unfortunately, deaths occur in hospital, it is worth stressing that a hospital death does not automatically result in a serious adverse incident investigation. The process is not part of the coronial system or service and does not exist for that purpose. It is unfortunate that, in many people's understanding, it is confused with the death certification and coronial system. They and their purposes are separate.

This has the potential to undermine the operation of the serious adverse incident process as a learning system, which is its principal purpose: for the system to learn from the investigation into such incidents. It operates to identify and promote learning. It is not a system based solely on records; it is heavily reliant on engagement with staff, and others involved in providing care, to determine their observations, evidence, viewpoints and insights into potential improvements. The scope and operation of the SAI system has changed several times over the years, and Sir Liam Donaldson's report recommends further change. If it ceases to be an effective means of identifying learning, or better alternatives emerge in the future for identifying learning, there is every possibility that the process will be stood down.

Lastly, we have concerns about the practicality of the proposed clause that makes it an offence not to comply with the Attorney General's requirement. Many people provide health and social care during someone's life. There is a lack of clarity on to whom the Attorney General would give notice and, indeed, how he would know who had provided care in the first place. To whom would he write if someone died in hospital, for example?

In summary and in conclusion, we have concerns about the policy rationale behind the proposed legislative change. The Attorney General already has the power to direct an inquest when he considers it to be advisable, and it has not been established that there is a problem that the legislation will solve. The scope of the proposals lack clarity and would have serious implications, resulting in more front-line staff being directed away from providing essential care.

Thank you for giving us the opportunity to provide this evidence. My colleagues and I are happy to take questions from members.

The Chairperson (Mr Ross): It boils down to the fact that, in your view, the power is unnecessary: in directing an inquest, under the current legislation, the Attorney General can carry out the functions that he needs and does not need anything additional; and, according to you, there is not really a problem to be solved. Is that a fair summation?

Dr Woods: Yes. That is it in a nutshell, Chair The powers currently possessed by the Attorney General allow him to access the information because, essentially, the coroner would access the information in any case and duplicate the investigation. The concern is the potential bureaucratic burden on the health and social care system.

The Chairperson (Mr Ross): You said that, in the vast majority of cases, deaths are reported appropriately. Then you talked about the issues that were in the media. Are you saying that those were anomalous, or that there were particular reasons why the issue arose? Is it the case that, for example, they were not recorded correctly?

Dr Woods: The broad statistic is that, currently, almost a quarter of deaths in Northern Ireland are reported to the coroner. I will turn to Fergal to give you the detail on the case in point in the Northern Trust.

Mr Fergal Bradley (Department of Health, Social Services and Public Safety): May I correct something for the record? At the start, Paddy said that there were 7,000 attendances at A&E, but there were 700,000.

The Attorney General's evidence referred to some of the incidents in the Northern Trust. Those date back to events in 2013, when the trust itself reviewed a number of SAIs that it had looked at over the previous five years. I assume that the Attorney General was referring to those cases. There were 20 cases in total, of which about11 involved death.

We are trying to avoid going into too much detail in specific cases. However, in looking at those cases, I would say that a number of them were reported to the coroner at the time. There were several cases involving, for example, stillbirth, which, at the time of death, under the legislation and in line with the rest of the UK, would never have been reported to the coroner.

In a couple of cases that came to light only a number of years after the event, nothing untoward was known that would have caused them to be referred to the coroner. As a consequence of a look-back exercise a number of years later, when X-rays or tests were looked at, they became aware that something had been missed, and there was, therefore, an issue with regard to the death. We are looking at those cases. There is also at least one case that you would logically have expected to be reported to the coroner at the time. So it is not true to say that there are never any concerns. However, overwhelmingly, we have cases that were reported at the time and cases that would not have required to be reported or came to light only as a consequence of something else that happened a number of years after the deaths. That is important, because, for the purposes of this, the coroner was contacted on the basis of the information that is before you. Therefore, if the information comes to your attention only some time later, which can happen, that is the point at which you contact the coroner. Even with that proviso, overwhelmingly, most cases are reported to the coroner within a day, a day and a half or two days — that sort of period.

Dr Woods: The key point is that the source of making the coroner aware of those cases emanated from the health and social care system.

Mr F Bradley: The trusts identified that they had an issue. They brought it to the Department, and that is how it came to light. That is not to say that we do not think that there are problems about the way in which the system works. We think that there are improvements to be made, which is what we have been looking at outside of the amendment. However, we are saying that this proposal does not address the problems where they lie.

I will refer to one issue that we have, which was highlighted in Sir Liam Donaldson's report yesterday. There will be some deaths whereby it is blatantly obvious that the case should be referred to the coroner, and there will be some whereby it is equally clear that there is no reason to refer. In between those, a huge number of cases come down to a matter of judgement as to whether they should be referred to the coroner. Part of our focus is on how to try to improve the consistency of the way in which those judgements are made. We have no underlying concern, however, that there is any cover-up or systematic avoidance of referring cases to the coroner. That is not to say that, occasionally, cases that should have been referred were not. We are saying that this sort of approach will not pick that up.

Mr A Maginness: Chair, you summed it up succinctly, and the witnesses have confirmed that that is, essentially, their view. Under section 14 of the Coroners Act (Northern Ireland) 1959, the Attorney General can look at all the papers that the coroner has and could, in such circumstances, ask for other documentation. Is that right?

Dr Woods: Yes.

Mr A Maginness: He has an overriding power to look at any single case and say, "By the way, having looked at all these papers, I think that there should be an inquest". That is his residual power in any death that occurs, whether in hospital or elsewhere.

Dr Woods: Yes.

Mr A Maginness: I just wanted to confirm that.

Mr McCartney: You read out those statistics, Dr Woods, and we all appreciate the work done by the health service. I took my father to an appointment at Altnagelvin Hospital this morning, and the professionalism in health care is exemplary, so whatever we are talking about here is in that context.

The amendment has been described loosely as a "second pair of eyes". Fergal mentioned improvements in the system. The Health and Social Care Board were here last week, and we discussed the Warde report, which was not submitted to the coroner but would have benefited a family at a particular time. Even with the framing of the amendment, there does not seem to be any compulsion to bring forward information such as that. Is that the type of improvement that you are looking towards for the future? That type of document should be submitted whether you are legally covered or not.

Mr F Bradley: To be clear: with regard to particular issues on that, you would need to have people with relevant legal expertise to explain the basis. I understand that there are a number of different types of judicial processes and interactions between different parties whereby parties are not under any legal obligation. I could not explain to you the rationale for that. The amendment does not touch on that.

In a wide range of cases, it is a matter of judgement. It is down to the individual person who is dealing with the case to say, "In my judgement, this needs to go to the coroner". They can act only on the basis of the information that is before them. We have been looking at systems like, for example, peer review. We have been piloting morbidity and mortality review systems. Davy will be able to talk about that. Basically, the idea is that, rather than a lot of these cases being left to individual judgement, within a matter of a number of weeks after the initial death being reported or not, as part of the normal process in a hospital, the teams involved on a multidisciplinary basis review a case. They reconsider and check that they are satisfied that it does not need to be reported as an SAI or should have been reported as an SAI and was. They also look at the death certification to ensure that they are satisfied with what has been recorded on the death certificate — that is very important because we need clear evidence of what people are dying from — and the completion of the death certificate and that, with regard to things like the coroner, the individual judgement is subject to testing out against the views of others.

We believe that, by moving towards that sort of a process — it is only one of the things that we have been looking at — we will get more consistency about what is being referred, and it will act as a check against individuals' judgements, because we do not believe that this is down to where these things arrive or to people deliberately trying to conceal information. It is down to people exercising different judgements based on their interpretation of the evidence. What you will find — it has come up in the look-back exercise — is that maybe tens of thousands of X-rays going back a number of years have been looked at, and another health-care professional, in reviewing what was previously looked at by someone else, identifies something that they were not aware of or missed. That can happen. We are saying that the approach that is outlined in the amendment will not pick up on that. We need a more systematic approach to improve the quality of what we are doing and to use the expertise of the people at the front line to try to ensure that the right decisions are made.

Mr McCartney: Should there be full disclosure if a case is referred to the Coroners' Court?

Mr F Bradley: As far as we are concerned, the coroner should have access to all the information that he needs. What I am saying is that, with regard to that legal issue, we do not possess that level of expertise. I am not completely clear on the nuances of why that happens.

Mr McCartney: No, I accept that, and neither am I clear. I do not want to say that I am across every detail, but there seems to be an acceptance. The coroner said that he felt that he should have had the document.

Mr F Bradley: We have tried to refer to this. When you put something on a statutory basis — say, an amendment that would put people in peril of a sanction for not complying with it — people will take legal advice. With respect, what will happen is that, when you take legal advice, your legal advisers will tell you what you should do and what you do not need to do to comply with the request. I do not believe that you will find that, in dealing with those sorts of things, it will necessarily have been health-care professionals who said, "Let us not share that information". They will have acted on the basis of legal advice. We are increasingly moving towards putting them in a position in which they need someone with a law degree to tell them how to interpret the information that they should provide, not by virtue of saying, "Let us hold something back".

The sheer volume of information that can be held about any individual patient across multiple locations can be quite significant. Unlike the SAI process — bear in mind that SAI reports are now pretty routinely shared with families, those involved or the patient if that person is not deceased — for an awful lot of these cases, what you are talking about is reviewing the files of hospital records. There is no "x marks the spot" when someone has done a nice little report that summarises the whole of the evidence and has gone through and analysed it in the way in which an SAI report would. We are looking at around 1,000 SAIs a year. Around one third of those involve deaths, quite a few of which will involve mandatory reporting for child deaths and suicides. In only a very small number of cases will someone have gone in and done work focusing on the evidence and summarising it for you.

Mr David Best (Department of Health, Social Services and Public Safety): It is also important to remember that the SAI report is also sent to the coroner, who will have disclosure of that. You mentioned full disclosure, but it depends what you mean by that. The relevance of the requested information is vital.

Mr McCartney: It is perhaps an impossible question to answer, but would that type of situation now not happen? A report that was obviously material was not sent.

Mr F Bradley: I could not absolutely guarantee that. I would need to have an understanding that I do not have about the legal process. The amendment will not address that. It is a nuance.

Mr McCartney: I accept that, but we would have an opportunity to make a further amendment to the Bill on that. As a layperson, when it comes out the other end, someone related what happened in a hospital, the hospital commissioned a report that supported the view of the family, yet it did not seem to go to the coroner. Something seems to be missing. Legally, nobody has said anything improper, but that could be done to assist the family. If that subsequently came out in an inquiry, it would look as if it had been concealed.

Mr F Bradley: There are limited circumstances in which an SAI report is not shared. That includes when the harm has been caused or is suspected to have been caused by a family member, or when there might be health concerns about a family member's or individual's well-being and the implications of sharing that information with them. However, it is very narrow, and trusts are required to record why they do not share them. Paddy will be able to talk about the specific responsibilities with regard to candour, and it was announced yesterday that we are also moving toward the introduction of a statutory duty of candour for organisations.

I cannot say that that would never happen, but it is extremely unlikely in the context of the way in which people would have treated that sort of information for many years. Unless the Attorney General will have significant resources and the insistence to trawl through information and records across quite a few cases, it will not be picked up. That is why we have done work on the morbidity and mortality review

I will ask Davy to outline some of the work that is being done on the independent review of deaths. He will be able to take you through that. Would you mind saying something on that, Davy?

Mr Best: We are considering bringing proposals before the Assembly to introduce legislation that would create a new medical examiner or medical reviewer system. That would be based somewhat on the Scottish model that will come into effect on 13 May, whereby a percentage of deaths will be randomly selected for scrutiny by the new Scottish medical examiner. There will also be an opportunity to look at another percentage of deaths in more detail.

I suppose that, with the prospect of what the Attorney General would like to introduce here, what are known as "authorised persons" could request a further level of scrutiny by the medical examiner. We are considering the possibility of bringing that into Northern Ireland.

Mr F Bradley: In addition to being able to select cases randomly, in Scotland there is a provision so that is someone is — I cannot remember the term; Davy will tell me — a legitimate person in the case, they can ask the independent medical examiner to review the case if they have a particular concern.

Mr Best: "Interested party" is the term.

Mr McCartney: Have you met the Attorney General to discuss it, or is just being done through this process?

Mr F Bradley: A certain amount of correspondence has gone backwards and forwards. I would hope that the Attorney General is aware of a lot of that work. He is certainly aware of the morbidity and mortality review system.

Mr McGlone: I want to gain a wee bit more understanding. Your submission states:

What specifically do you require to be clarified? Can you give us a synopsis?

Mr F Bradley: I will turn it on its head. We are civil servants; we work on policy and bring forward policy proposals for legislation. Were I to bring forward a proposal, on the normal basis, to give anyone powers to access information or records about ordinary members of the public, in any circumstance, I would expect to be asked to articulate why that power was necessary and proportionate, why that person was the right one to have the power and what the outcome would be. We have not seen anything systematically that states, first, that there is an issue of non-reporting; secondly, that this response is proportionate; and, thirdly, that this will have the impact or the outcome that you would desire, which we would share. We want to be sure that the quality of information and decision-making in referring issues to the coroner is as sound and consistent as possible.

Mr McGlone: Yes. That is about the scope, insofar as the perception is that it may be broadened a bit. The last sentence states that, were his amendment accepted, the Attorney General may require:

Why should he not? Say, for example, something happened externally to a hospital that required that person to be in hospital but that it did not become apparent until later — say, in a post-mortem — that perhaps he or she took the wrong medication or something like that, which affected that person adversely. In such circumstances, why should the coroner not have access to that information?

Mr F Bradley: If you are going to give someone the power, it is important to specify whom they can ask the information for. Does that definition include, for example, a family member who is a carer? Does it include the personnel records of all the staff involved in providing care to the individual? If the person has sought alternative therapy or medical treatment, does it involve going to the chiropodist? There is a significant burden here. From whom do you ask for information that may be relevant to the case? That is what we are trying to get to. We are not clear where this ends and its full extent, and we feel that there should be some clarity on that.

Mr McGlone: Should that be tightly specified?

Mr F Bradley: We are saying that we are not clear how you would specify it to achieve the purpose that the Attorney General might want.

Mr Elliott: Thanks for the presentation. From what you have said and from reading your presentation, is it fair to suggest that a lot of it is down to clarification? Quite a bit of it is because you do not know exactly what the Attorney General may be looking for that is not currently provided for.

Mr F Bradley: No, it is more than that. We are not clear on what basis we are doing this, but we are also not clear whether it is a proportionate response or what its desired effect is. The objective, which we share, is to ensure that deaths are appropriately reported to the coroner, that it is consistent, timely and so on. We do not see that the amendment would have that sort of impact. We are talking about 7,000 deaths a year. How many cases would the Attorney General look at randomly, or through any other process, to hit on something?

I apologise for the use of language, but the point is that it would be like buying a lottery ticket. We are trying to look at having systematic approaches that make sure that professional judgements are exercised appropriately and that the process works systematically and has checks and balances, which means that an elderly person who dies on his or her own at home, with no family members, has as equal a chance as anyone else of having the circumstances of his or her death investigated. It is reasonable that the odds of that driving up quality are better, because, ultimately, if you want to introduce a system in which all 7,000 deaths in hospital a year are scrutinised, the resource implications are such that the whole system could not bear it. It is about trying to ensure that the checks and balances are sufficient and proportionate to ensure that the quality of what is being done is right, and the decision-making is sound.

Mr Elliott: You said that it is about a lot more than the examples that I gave. However, surely the key issue is clarification. You said that, in principle, the Department has no objection to the Attorney General having the power to access the information, but you then put in your caveats. You are saying that you have no difficulty with the Attorney General getting more information, but you are not sure what all that information is, why it is required and why it is not being provided at the moment. Have you talked to the Attorney General about those issues? You say that, in principle, you have no objection but that you do not support the current proposals.

Mr F Bradley: Obviously, the Attorney General's approach has been to bring forward this amendment. Let me explain what our position is. We have said that we have no objection in principle — nor do we — and I have been asked, "Why not give the Attorney General the power?" My response and my answer to your question is this: why not give someone else the power to do something? The basis on which we bring forward legislation is that there is a reason to give someone a power. We would not apply the threshold if there is no particular reason not to give someone the power, particularly when it is a fairly wide-ranging power to access the records of patients and clients. We do not object in principle; we are just waiting for someone to articulate to us why he should have the power, why it is proportionate, and how and why they believe —

Mr Elliott: That is what I am trying to say. You do not support the current proposals because you are not clear.

Dr Woods: I think that it is fair to say that we are struggling to see the value this approach would add —

Mr Elliott: I accept that.

Dr Woods: — to what is already in place and, indeed, other areas of work that we are progressing.

Mr McCartney: You do not accept the theory of a second pair of eyes.

Mr F Bradley: There are multiple pairs of eyes. If you have a second pair of eyes, you are going to have systems in place to check. It has to be something that can deliver the outcome that you want. Davy, what percentage of cases will be randomly selected in Scotland?

Mr Best: It will be 10% of cases that would not be referred to the procurator fiscal, who is the equivalent of our coroner. Last year, we had about 15,000 deaths, and 21% or 22% went to our coroner, so there would be a 10% difference. Are there any mathematicians here to work that out?

Mr F Bradley: Twelve hundred.

Mr Best: About 1,200. Thank you, Fergal. Under the regional mortality and morbidity review system, which we are hoping to roll out across all the trusts, all deaths would be considered by multidisciplinary teams in the hospital. So a number of additional sets of eyes will look at the cause of death and the care that has been provided. That will provide greater assurance than is currently available. If we then went one step further and introduced independent scrutiny, that would be additional independence to that provided through peer scrutiny.

Mr Elliott: Chair, I think that I am there. I am just trying to get a handle on it because it is quite difficult to draw out. In principle, the Department does not seem to have a difficulty, but it needs a lot of clarification.

The Chairperson (Mr Ross): They do not feel it is necessary.

Mr Elliott: They are not sure. It might be helpful if they and the Attorney General discussed it. It may clarify it, or it may make it even more confusing. I do not know, but I take your points.

Mr McGlone: You are the experts, and I just want to gain a wee bit of understanding. At what stage could those powers interfere with police powers?

Mr F Bradley: The legislation would deal with that.

Mr Best: Which powers are you talking about, Patsy? Is it these powers?

Mr McGlone: Yes. If there is a perception, for example, that you are moving into a criminal investigation — say, someone wound up dead as a result of negligence — so that a criminal investigation could be going on at the same time, is there any potential for muddying the waters with too many people being involved, whereas the perception of the Attorney General is that he is normally at arm's length from it. I am thinking of the outworkings.

Dr Woods: As I said, multiple authorities may have an interest in a death, of which you have mentioned a few. We already have in place a memorandum of understanding between our Department, the Health and Safety Executive, the PSNI and the Coroners Service to address that very issue. Without knowing the details, I dare say that there is a potential, and it would be necessary to look at the memorandum of understanding more extensively to ensure that the risk is minimised and that all parties are clear about their obligations and role in these scenarios.

Mr Best: At the outset, the memorandum of understanding establishes primacy in, or who takes charge of, that investigation. I am not sure that the practicalities of the Attorney General knowing all the details at that stage would override anything that is already in place. I do not think that that would be the case.

The Chairperson (Mr Ross): Thank you very much for your comprehensive answers. It was very valuable.