Inquiry

MR. BOYLE KC – Opening Statement

Reference: ‘Urology Services Inquiry’ website – Day 8 Transcript 10 November 2022 (pp. 109-134).

Opening Statement Chair, Dr. Swart, Mr. Hanbury. This is the opening statement on behalf of Mr. Aidan O’Brien, Consultant Urologist. It is made in the hope that it will assist the Inquiry in the work that it is undertaking. Mr. O’Brien welcomes the opportunity to provide the Inquiry at this early stage in its task with some background and context and to highlight a number of concerns that he has had about the Urology Service commissioned of and provided by the Southern Health and Social Care Trust and its governance. You will be relieved to hear that I do not propose to go over Mr. O’Brien’s training and background, Mr. Wolfe very kindly did that job for me on Tuesday.

Following Mr. O’Brien’s appointment as a consultant in July of 1992 he remained a Consultant Urologist from then until 17th July 2020 when his employment ended. His career at the Trust accordingly spanned the best part of three decades. Over the course of his career, he would have conducted many thousands of consultations with patients and their families and thousands of operations.

From July of 1992 until the appointment of a second consultant in 1996 he was the only Consultant Urologist at the Trust and provided a continuous, acute and elective urological service. You have heard how he effectively built up the service single-handedly. The scale of the task he undertook should not be underestimated. As a single consultant with a patient population of approximately 290,000 citizens, his patient to urologist ratio was one of the worst in the whole of western Europe and the urological service being provided at that time was grossly inadequate.

So it was that following his appointment, Mr. O’Brien committed himself wholeheartedly to the task of enhancing and improving that service for the benefit of the patient population he served. And his wholehearted commitment to that service and each and every one of his patients endured for the entirety of the remainder of his working life. His has been a life of selfless dedication to his patients. The reality is that throughout his tenure as a consultant, the Urology Service at the Trust was seriously and significantly underresourced for year after year after year.

The lack of resources and increasing demand is not a recent development. It is not a Covid-related development or a Brexit-related development. There has been a profound and continuous failing, presided over by Trust management, the Health and Social Care Board and the Department of Health for over 25 years to adequately resource the Urology service at the Trust.

To have found ourselves as we sit, or in my case stand, here today, with reports that Urology patients have had to wait six years, and in some media reports, seven years for a first appointment is a scandal and an outrage. Mr. O’Brien, like so many of his dedicated colleagues, urologists, radiologists, oncologists, anaesthetists, junior doctors, nurses and others, worked tirelessly within a system which has been failing its Urology patients in an appalling fashion.

Mr. O’Brien worked extraordinarily hard for decades to assess and review patients and provide the treatment which patients required. He worked so hard to try and mitigate the very risks posed by under-resourcing, under-resourcing over which he had no control but regularly raised. He committed to undertaking additional sessions. He continued to use his usual operating sessions even when he was on periods of annual leave. He used operating sessions vacated by other surgeons when they went on annual leave. He used administrative time and Supporting Professional Activity time to operate. He availed of additional operating sessions at weekends. He worked extended operating days. The Trust knew he was working every waking hour, and so it continued year on year.

In March of 1997 in his own paper entitled “The Future Development of Urological Services” which is in the disclosure, Mr. O’Brien, drawing upon his own experience working at the Trust, his familiarity with national and international standards, and increasing awareness of men’s health issues, pointed out that the demand for urological services far exceeded the existing level of service provision by the Trust, and that demand would be ever increasing.

On Tuesday afternoon Mr. Wolfe mentioned the recent model, moving to one of seven consultants, which has been introduced but bound to fail from its inception. Seven consultant urologists. Mr. O’Brien made precisely that point in 1997 – 25 years ago. And yet, despite that warning and issues arising ever since, that imbalance has never been properly addressed and the dire under-resourcing, with the burdens that places on staff and the delays in treating Urology patients, has sadly continued.

For years Mr. O’Brien has been raising concerns about workload and patient safety in his annual appraisals and in the job planning process, and he did so in the clearest of terms. In his appraisal for the period 2011-2012, ten years ago, he stated the following:

“The main issues compromising the care of my patients are my personal workload.”

He then made a reference to the number of sessions he was having to undertake before adding:

“Almost all inpatient care and administrative workload arising from those sessions has to be conducted outside of those sessions.”

The following year he stated:

“I work long hours every day, contracted or otherwise, paid and unpaid, in an attempt to mitigate the worst outcomes.”

His appraisals over the years, the Inquiry may feel, are a valuable resource, setting out, as they do, contemporaneously detailed descriptions of the extent of his commitments, the roles he was performing, the surgery, the clinics, the different locations he was working at. These are not documents looking back with the kind of hindsight we heard just a moment ago. These are not documents that are some after the event, exculpatory production for the purposes of an inquiry. He was telling the Trust, at the time, of the compromise to the care of his patients, the factors contributing to it and the personal length he was going to try and mitigate it. He also raised concerns over the course of many years during the job planning process. He frequently rejected suggested job plans as they inadequately reflected the role that he was performing. He didn’t sign the majority of the job plans and he was perfectly open about it. He expressed himself, again clearly, saying that the allocation was “inappropriate, inadequate and unsafe”. Unsafe. He was warning the Trust management that his intolerable workload and the inadequate provision for his administrative burden was “unsafe” for patients.

In an e-mail in December of 2013, Mr. Robin Brown, then Clinical Director wrote about Mr. O’Brien and I quote:

“I do recognise that he devotes every wakeful hour to his work and is still way behind…”

In relation to his administration.

“… Aidan is an excellent surgeon and I’d be more than happy to be his patient. I would prefer the approach to be: How can we help?”

But little changed and there was little help.

The Trust have, therefore, known that the excessive demands on his time reviewing patients, operating, performing the role of Urologist of the Week and the other significant responsibilities he had from time to time, compromised his ability to, in addition, address certain aspects of administration, which he was telling them was unsafe, but they condoned it. They knew he did administration at home. They knew he did it when he was on leave and they knew, in terms of triage, that he wasn’t the only one who was unable to triage routine referrals; it was the Trust who created the informal default process that Mr. Wolfe mentioned this morning, in the event that referrals were not triaged whereby the appointments office would list in accordance with the category of urgency designated by the referrer. That wasn’t Mr. O’Brien’s bright idea. One might have thought that the solution to that problem might be to employ more staff or permit existing staff more time, or preferably a combination of both. Instead, the default position appears to have been not to commit resources to Urology to address the problem.

Earlier this year, in June, we heard evidence in relation to the case relating to Patient 10 and it’s a classic case in relation to this particular point. Let me read to you from his comments of 25th January 2017 regarding the final draft report of the Root Cause Analysis or the SAI in that case. Mr. O’Brien wrote of triage in response:

“Another system or method or time was needed for them to be done if by a consultant at all and the triage of non-red flag referrals should be revisited to discuss who, when and how this challenge can be satisfactorily resolved.”

There was no response to Mr. O’Brien’s proposals in his response to that SAI.

It was thus against a backdrop of years of him expressing his concerns about overwork and appalling underesourcing that on 23rd March 2016 he was called to a meeting at which he was handed the letter that you have heard about which raised concerns about his administrative backlog, the triage, the records at home, the delay in dictation after clinics.

The letter begins: “We are fully aware and appreciate all the hard work, dedication and time spent during the course of your week as a Consultant Urologist.”

It is not a formal letter in the sense that it refers to any particular process. It is not written pursuant to any Trust policy or procedure. It doesn’t refer to any guidelines that he has supposedly breached. It makes no suggestion of misconduct or poor performance. It’s not a warning, formally or informally. Mr. O’Brien asked what do you want me to do about it? What was the Trust’s plan moving forward? What did they suggest? And as you heard he was met with a shrug of the shoulders. You needn’t take his word for that. As the report of the investigation subsequently found:

“There appears to have been no management plan put in place at the time and Mr. O’Brien seems to have been expected to sort this out himself.”

He had been trying to do that for years.

We have an organisation that knows there are issues, either systemic or individual or both, either way, where was the governance addressing that? No changes to the underlying systemic issues. No additional support provided. No support identified. No plan drawn up. No additional time. That was in the March of 2016 and there was no follow up.

What Mr. O’Brien did not appreciate, or know, was that come September of 2016 some steps were being taken that he was not aware of. First, on 7th September 2016, the Trust sought assistance from NCAS, as you have heard now known as NHS Resolution, which, and Mr. Wolfe read to you their mission statement, provides expertise on resolving concerns and disputes fairly, sharing learning for improvement, preserving resources for patient care. The latter, that is NCAS, provided some very sensible advice or options to the Trust. They encouraged the Trust to meet with Mr. O’Brien and agree a way forward. They advised relieving Mr. O’Brien of theatre duties to allow him to clear the backlog. They advised that Mr. O’Brien would likely require significant support. They offered to attend the meeting to facilitate what you may feel is a very sensible approach or plan.

The Trust, for reasons the Inquiry will wish to explore, ignored that advice and didn’t communicate with Mr. O’Brien about it at all. He was thus not afforded the opportunity of acting in accordance with an action plan which NCAS were offering to assist with. NCAS themselves recognised that further input from it would be likely so they kept their file open. Mr. O’Brien first discovered that his employer was advised to relieve him from operating for a period and adopt a collaborative approach in October of 2018 – two years later.

Then on 13th September, as you’ve heard, there was an Oversight Committee meeting that had been convened and rather than any formal process being advanced, a less formal alternative approach was proposed by Ms. Gishkori, the Director of Acute Services, and agreed by Dr. Wright, Medical Director. But again, the very existence of that meeting and the plan proposed wasn’t discussed with Mr. O’Brien. That was followed by a further meeting on 12th October 2016 and yet again no progress was made to try and address the areas of concern. Mr. O’Brien was still given no support, no additional time away from theatre or plan of any kind to work to.

Mr. O’Brien had himself needed elective surgery, which was planned for mid-November of 2016. In November, some six or seven months post the March letter, having received no plan or proposals from the Trust, he then made a suggestion about clearing the backlog. He offered to do it while he was convalescing after his own surgery. He was due to be off until the early part of 2017.

The Trust, which two months beforehand had rejected the NCAS suggestion that the Trust should relieve him of operating to allow him to address his administrative backlog while he was in work, instead agreed his proposal that he could address the backlog when he was off sick from work. That, of course, required him to have a host of patient medical records at home, which was one of the very criticisms he faced, but that didn’t seem to concern the Trust in these circumstances at all; presumably because it rather suited its purposes.

The duplicity and hypocrisy should not be lost on anyone.

From a governance perspective we hope that the Inquiry will acknowledge the responsibility on the Trust for welfare here. Mr. O’Brien was volunteering to clear this backlog literally from his sick bed. Sometimes, Panel, we can be our own worst enemies, dedicated employees or public servants in this instance who feel a duty and feel they can and will be able to do it all. There is an onus on you as a Trust or an employer to protect such individuals from themselves at times. By doing so, of course, you are fulfilling your duty to patients also, overworked, overstressed, overburdened staff are not best placed to serve patients, try as they might.

After his illness and the four-week period of exclusion which took place in the early part of 2017, Mr. O’Brien duly returned to work on 20th February. He returned under the shadow and stress of being the subject of an ongoing investigation and he returned subject to an agreed Return to Work Plan. For the avoidance of any doubt, his practice itself was not restricted in any way. There was a process of monitoring in relation to triage, note keeping, storage and the like.

From the February of 2017 until the Case Manager reported in the October of 2018, there was, therefore, a plan in place which he complied with. In October of 2018 the Case Manager concluded, Mr. Khan, he worked successfully to the action plan during this period. And all of this, therefore, rather begs the question: Would we even be here if the Trust had acted on the very issues that Mr. O’Brien had himself been raising in the likes of his appraisals and his job planning for years, or put in place proper plans for addressing administrative concerns in 2014, ’15, or ’16?

The investigation which commenced in late December 2016, as you have heard, was carried out by Dr. Chada. Mr. O’Brien cooperated with that investigation. He was interviewed more than once, answered the questions asked of him and provided relevant materials. A report was produced by Dr. Chada in June of 2018, some 77 weeks after Mr. O’Brien was told he was under investigation, even though the Trust policy dictated that such investigations should be concluded within four.

Save for the initial very short period of exclusion, Mr. O’Brien continued to work full-time reviewing patients and operating. He responded to Dr. Chada’s report within three weeks on 10th July 2018 and the Case Manager, Dr. Khan, as you know, provided a determination on 1st October of 2018. The Case Manager’s recommendations were that Mr. O’Brien should be referred to be dealt with before a Trust Conduct Panel. That recommendation was made on 1st October and no such disciplinary meeting ever took place.

It is important that this Inquiry appreciate that the investigation alone did not establish any facts in relation to Mr. O’Brien or his practice. That was the purpose of the referral to a hearing for those issues to be ventilated and findings to be made, save of course where Mr. O’Brien had himself made admissions during the course of the investigation, which as a matter of record he did.

From October of 2018 until 17th July 2020, a couple of months short of two years, a formal hearing, at which any evidence relating to Mr. O’Brien could have been tested, never took place. When his employment ended on 17th July 2020 it had been four years and four months since the March 2016 letter, with no conduct meeting or performance meeting or hearing of any kind, nor any hearing at which any finding was made in relation to him.

The Case Manager in October also recommended that moving forwards, as you have heard, the Trust put in place an action plan with input from NCAS. That recommendation, as you know, was not actioned and no plan was ever suggested. The irony of that should be lost on no one. NCAS had offered to do just that in September of 2016 – two years earlier. And whilst the Trust never disclosed that fact to Mr. O’Brien, he found out that NCAS followed through on their promise to keep the file open and not only that, attempted to assist by contacting the Trust in January, March and May of 2017 but the Trust ignored their attempts and their offers of help. Why? Why did the Trust ignore the attempts of the National Clinical Assessment Service? Why did they ignore the help on offer? Why did they not tell Mr. O’Brien NCAS had offered to intervene to help?

On 27th November 2018, Mr. O’Brien lodged a formal grievance against the Trust in relation to its handling of the concerns about his administrative practises. It is a lengthy, detailed document and it spells out, in stark terms, very real and disturbing failings on the Trust’s part, many of which have been laid bare already in Mr. Wolfe’s opening. That grievance itself was not resolved before Mr. O’Brien’s employment ended in July 2020, the best part of two years later.

It is also worth noting that Mr. O’Brien and his colleagues had already arranged to meet with Senior Trust Management on 3rd December 2018 to discuss and agree upon the expectations of the role of Urologist of the Week, triage and waiting list concerns. However, on 30th November, two days after he submitted his grievance and three days before that very meeting was due to take place, the meeting was cancelled without explanation. Eventually, approaching the age of 67 in March of 2020, Mr. O’Brien submitted notice of his intention to retire from full-time employment at the end of June. He did so having received beforehand assurances of his ability to return part-time thereafter, a situation which was not uncommon at that time, particularly at that time when we were in the midst of the Covid pandemic.

Nobody suggested to Mr. O’Brien that he would not be able to return part-time because there was an ongoing HR issue. He was not contacted by HR, or anyone else for that matter, to explain that the Trust had such a policy in existence. Nor was he contacted by HR or anyone else in the weeks or months prior to June to explain to him that regrettably he would not be able to return postretirement. He continued working full-time, unrestricted, as committed as he ever was to his patients.

On 7th June 2020 Mr. O’Brien sent an e-mail regarding patients to be listed for admission for surgery, there was nothing serious or unusual about that course at all. The following day, on 8th June, Mr. Haynes, in a telephone call, informed him that the Trust had a practice of not reengaging people with ongoing HR processes. Leaving aside the fact that the ongoing HR processes should clearly have been resolved months, if not years, beforehand, this was news to Mr. O’Brien and he had been working away continuously, since March, in the expectation of retiring and returning parttime. So this was very concerning.

Incidentally, Mr. Haynes raised no issue at all about the e-mail which had been sent the previous evening, on 7th June, about the patients.

Not surprisingly, Mr. O’Brien, who had always harboured the wish to continue to care for patients and serve the public of the Southern Trust, took the view that if the Trust did not reengage people who had retired in such circumstances then he would revoke his intention to retire. If he didn’t retire then of course the question of reengagement post-retirement didn’t arise. So on 9th June, he duly revoked his notice of intention to retire.

The Trust refused to accept that. They told him that his employment would end on 30th June and a return would not be facilitated. That resulted in pre-action correspondence being sent to the Trust on 23rd June with talk of an injunction and the like. The Trust asked to have until 17th July 2020 to respond. 17th July 2020 being the date upon which it is said Mr. O’Brien retired.

The Director of Legal Services, on behalf of the Trust, by letter dated 7th July 2020, raised an issue by way of a recent development, namely the allegation that two out of ten patients had not been added to the patient administration system, the PAS. There were no other concerns raised in that letter.

Remarkably, and this Inquiry may think not at all coincidentally, only after revoking his intention to retire, and shortly before the 17th July response date, on 11th July 2020, Mr. Haynes sent Mr. O’Brien a letter, referring to the addition of two patients out of ten for surgery who’d not been added to the patient administration system at the appropriate time. In other words, what was being alleged was that Mr. O’Brien had delayed those patients’ surgery by having failed to add them to the system at the appropriate time. It was an allegation which was completely untrue.

Mr. Haynes and the Trust had a month from the 7th June e-mail to get their facts straight in relation to that. All that it required was for the PAS to be looked and checked in a fair, unbiased, objective, competent and impartial manner. It simply wasn’t true. What is worse and all the more disturbing is that Mr. Haynes had been privy to e-mail correspondence in relation to the patients which showed that those patients had been added to the system at the appropriate time, and yet it was that untrue allegation that two out of ten had been delayed that led to the so-called informal lookback exercise/review of records to January 2019, carried out by the Trust and the springboard for what has followed.

This false allegation about the two patients was repeated by the Trust to the Department of Health in the Early Alert Notification of 1st August. The Trust was informed during the hearing of the grievance on 7th August that the allegation was untrue. Even so, and when the Trust was tasked with checking the Minister’s draft statement for factual accuracy, the Minister repeated the allegation unaltered in his statement to the Assembly on 24th November when the Public Inquiry itself was announced. Thus, when considering the events which led to the establishment of this Public Inquiry, you are invited to scrutinise, with the greatest of care, whether the instigation of this Trust-led informal Lookback Review was bona fides. Was it borne out of some wish by some that Mr. O’Brien should not be permitted to keep working there? Until the two out of ten issue arose in July there had been no suggestion of a lookback, no issues raised at all about Bicalutamide, the use of which incidentally by him in relation to patients was widely known and discussed at MDTs attended by other urologists and oncologists.

So far as the informal Lookback exercise itself goes, the Trust did not involve Mr. O’Brien in that at all before passing on information to the Department.

Even though these were his patients, treated by him and others, without any concerns being expressed by anyone in relation to medication, consent, treatment and so on, he was given no opportunity to have any input into that exercise at all. He was frozen out. And before its details were communicated to the Department, he was given no opportunity to comment or correct.

The Trust also invoked the SAI process, again without involving Mr. O’Brien in that in any way. The Inquiry should have serious concerns about that process, given the manifest unfairness in proceeding with it, without asking for Mr. O’Brien’s comments until after the authors of the reports had expressed their opinions.

In addition, the SCRR process was embarked upon, again without involving Mr. O’Brien in that in any way. He has sought information in relation to that particular process and what’s being adopted and whether he is to be involved, however he has received no substantive response. Had he been asked, he would have been happy to contribute.

And so it is that another process where conclusions will be reached, reports drafted and families informed, before Mr. O’Brien has been asked for his input at all.

There has been very limited disclosure thus far of SCRR reports. In the one SCRR report he has been able to review in detail, the contents of which the Trust appear to have accepted because it has been copied to the patient’s family, the author has made basic mistakes of fact and flawed opinions, such as suggesting there were elevated PSA readings, when there were not, suggesting Mr. O’Brien was the Chair of an MDM in 2009 when they didn’t exist, and claiming that Mr. O’Brien had been the Chair of an MDM in 2012, when incorrect prostate cancer recommendations had been made. Mr. O’Brien hadn’t even been present at the MDM, let alone Chair it. Thus in the one SCRR he has been able to comment upon and check there are egregious errors. The Trust appear to have blindly accepted it. Scrutiny of the documentation shows that the author of that particular SCRR completed the task in just 90 minutes.

It was, therefore, with considerable alarm that we listened to Counsel to the Inquiry open this Inquiry on the basis that you may be prepared to permit space for ventilation of serious and significant disputes about the clinical aspects of cases and only where considered necessary in furtherance of the Terms of Reference. Findings were referred to and themes already having been identified, all without any input from Mr. O’Brien or even full disclosure to Mr. O’Brien, but with a very clear signal that the outcomes of those SAIs and SCRRs on clinical aspects of care, are going to be, and it appears have already been, accepted. Yet the Terms of Reference say, expressly, the clinical practise of Mr. O’Brien is being investigated by the GMC and it would, therefore, be inappropriate for the Inquiry to encroach on the GMC’s remit.

Not only that, and without prior notification to Mr. O’Brien or prior disclosure to him, detailed reference has been made to reports from the RQIA and RCS – we appreciate of course that those have only been recently received – but neither Mr. O’Brien nor his legal team have even seen those documents. A number of references were made to clinical aspects and rehearsed in opening and at length.

There are ongoing concerns about the fairness of the process that has been adopted and which I have referred to going way back to Trust time thus far. He’s a 69 year old gentleman. He does not have a secretariat of information managers or staff that he can call upon and self-evidently he is not a government department. Of the three Core Participants, he’s a single individual.

There was an initial disclosure, as we know, of some 217,000-odd documents. He was served with a Section 21 notice which for him was a massive undertaking personally. There were patient hearings in September to prepare for, statements of witnesses for next week being served, including a statement from Mr. Haynes who is a key witness from his perspective with a 5,000-page witness bundle, assistance to me for preparation of this opening and a further 100,000 pages of Trust disclosure within the last with two weeks. We understand from the opening that perhaps there may be a further 100,000 documents that yet remain to be provided.

It’s simply impossible to expect him to be able to cope, particularly with a protocol that requires suggested lines of questioning of witnesses when there’s insufficient time to consider what or even where the relevant documents may be and if further records are to provided, that may be relevant to lines of questioning he may wish to explore.

The production of his Section 21 response, some 200+ pages, placed an intolerable amount of pressure upon him. He has been relentless in his attempts to comply and he is physically and emotionally exhausted by the strain of all of this. It is not just the volume of the information provided, but the nature of that information, you will not be surprised to hear, is a cause of considerable distress. It is important that he does not become overwhelmed by the process, as not only will the Inquiry be deprived of his ability to fully participate, but his own health may deteriorate.

On his behalf, we invite this Inquiry to consider the following:

Why the Urology service has been so seriously underresourced for decades?

Given the contents of Mr. O’Brien’s appraisals and correspondence around his job planning about the inadequacies of the resourcing and time allocated for administration for years prior to 2016, why didn’t the Trust obtain and provide additional support?

We were told yesterday that support of such nature has now been obtained. Why has it taken the establishment of a public inquiry, decades later, before that occurred?

Why was the Urology Department such an outlier in terms of resourcing, as evidenced by the waiting lists, when compared to other departments within the very same Trust?

When they knew that clinicians did not have the time to triage all referrals, why not obtain additional support rather than adopt a policy of deferring to the referrer’s categorisation?

Did the Trust inform the Commissioners of Healthcare or the Department of Health that administrative backlogs of this scale were occurring? If so what was the response? Was there any additional funding provided for example?

Why didn’t the Trust provide Mr. O’Brien with a plan to address the administrative backlog in March of 2016 at or after that meeting?

Why did they ignore the advice of NCAS in September 2016?

Why did the Trust refuse or ignore the offer of NCAS to facilitate and be present at a meeting when an action plan could have been agreed in September of 2016? Why did the Trust continually refuse to accept the offers by NCAS to review the ongoing situation in late 2016 and up until May 2017?

Why were the recommendations of the Oversight Committee not actioned?

Once the investigation commenced, why did it take 18 months for the report to be produced?

Why were the recommendations of the Case Manager at the end of that process not followed? No hearing to establish the facts? No NCAS action plan put in place?

Why was Mr. O’Brien’s grievance not answered before his employment ended the best part of two years later?

When, if ever, did the Trust introduce a policy or practice that anyone under a HR process could not be reengaged?

What checks and balances did the Trust have in place to ensure that allegations such as those made by Mr. Haynes regarding the two out of ten were fact checked before being acted upon?

Was the department of Health made aware of the requests for support, the NCAS offers of help and factual inaccuracies before the Minister announced a public inquiry?

Why has Mr. O’Brien not had appropriate disclosure and been fully involved at appropriate junctures, during the SAI and SCRR processes?

Has anything improved since Mr. O’Brien left the employment of the Trust?

If improvements have now been made, why did that not happen sooner, many, many, many years ago?

Chair, Mr. O’Brien, as you know, has attended each day of the patient hearings to listen to the accounts that the patients and their families have given in relation to the circumstances that you are considering. His focus, throughout his entire professional life, has been to do the best for all of his patients, notwithstanding the circumstances and he fully and frankly acknowledges the difficulties and the concerns that have been raised in the context of the investigation thus far and this Inquiry.

Madam, those are my observations.