She is the teenager who was allowed to stay at the home of Arthur McElhill in Omagh even though he was a convicted sex offender. The girl was known to the Western Health Trust for she had been placed on its Child Protection Register.

However, she received scant protection, being allowed to visit the McElhill home and regularly stay overnight. It has emerged that a social worker did not make the necessary checks after being made aware of Mr McElhill's criminal record.

The girl was only removed from the house after a radio conversation between two police officers dealing with an incident involving the teenager's mother was overheard by the area's sexual offences risk manager.

If the manager had not heard that conversation, the teenager might well have been in the house the night it was set on fire killing Mr McElhill, his partner Lorraine McGovern and her five children.

The whole tragic case was bedevilled by failings in the social services in the area. Some social workers were inexperienced — one had been trained outside the province and did not know local legislation — and another was new to the profession.

The social work team leader — in charge of 10 members of staff — had only worked part-time for four years.

The investigation into the care given to the family prior to the fire resulted in 63 recommendations being made to bring services in the area up to scratch.

What the investigation found was a catalogue of errors, and, even more alarmingly, inherent weakness in the system. Agencies involved with the family did not communicate effectively with each other; vital information was not passed between them and what can now be seen as clear pleas for help from the children were not heeded.

That is an appalling state of affairs. As ever in such cases we are told that lessons have been learned and that such failings could never happen again. The Western Health Trust says immediate action has been taken to address the most pressing areas of concern.

The Trust has also established an Improving Quality Together project in conjunction with the Western Health and Social Services Board aimed at improving the quality of child protection services in the area.

The Health Minister has invested £2m in frontline child protection services throughout Northern Ireland and almost £15m will be invested in child protection and family support services over the next three years. Some £11m of that money will go on new services.

This all sounds very impressive. Action has been taken and significant sums of money have been given to the service.

But the same people who oversaw the litany of failures in the first place are still in their jobs. The inexperienced social workers have undergone a chastening experience, but, presumably, still need proper supervision which they didn't get the first time.

The people who ignored all the warning signs are still working in the various agencies. Communication between the agencies is supposed to improve through the adoption of common standards of both supervision and of recording information.

There are only two slight issues of mitigation in this whole sorry affair. One is that the social services workers were under enormous stress with heavy caseloads.

The other was that no one could have foreseen the tragedy that unfolded. There was no indication that Mr McElhill would have poured petrol around the house and set it on fire with the whole family inside.

It is surprising that no disciplinary action has been taken against anyone. It is less surprising that no one has honourably fallen on their own sword in recognition of the shambles. It is still not too late for both options.