Coroner: from what you say the system now is fundamentally different PM: yes Coroner: are the changes made pursuant to the issues that arose in Colette’s case? PM: yes I believe so Coroner: you highlight there was no continuity, it was a reactive system PM: yes

Coroner: from what you say the system now is fundamentally different PM: yes Coroner: are the changes made pursuant to the issues that arose in Colette’s case? PM: yes I believe so Coroner: you highlight there was no continuity, it was a reactive system PM: yes