for looking at the outcome of babies in neonatal units and to look at adverse events happening to babies in neonatal units. he wants all patient incidents to be entered into a system which automatically raises the flag when an unusual pattern emerges. if we track these things in real time, you can trigger action. you can say, there s something untoward happening here. it s outside the limits of normal variation. we need to look at it. for years, he s also been calling for medical examiners, independent senior doctors who look at all deaths which aren t seen by a coroner. it was recommended by the inquiry into dr harold shipman, the greater manchester gp, thought to have killed 250 of his patients. that recommendation was made in 2003. 20 years on, those examiners arejust being introduced. do you think that would have made a difference here? i think it might have made a difference, yes. i think that if somebody had asked difficult questions,