The HSE have advised that this report is currently subject to detailed internal considerations with relevant staff to ensure learning is maximised and further action is taken as appropriate. The report and full details of associated action will be made available in early Spring 2013. The HSE also advised that following the incident in Gleann Alainn there was an immediate management review and a series of changes including, the appointment of a new Unit Manager and the number of places available in the Unit was reduced. A detailed programme of management intervention and support was initiated and an external review of the incident was commissioned. HIQA undertook a further inspection of Gleann Alainn in May 2012 and found that considerable progress has been made since the previous inspection.