The deaths of four babies in Northern Ireland hospitals following the outbreak of a bacterial infection might have been avoided if better practices were in place, a Stormont committee has heard.
An independent review examined the death of a newborn baby at Altnagelvin Hospital in Londonderry in December and three more babies at the Royal Jubilee Maternity Unit in Belfast in January after pseudomonas infections linked to water taps.
Professor Pat Troop, author of a report into the tragedy, said some parents complained that the threat posed by the deadly bug had not initially been fully explained to them.
Her report found that the bacteria spread from contaminated taps to the children when babies were washed during nappy changes or when tap water was used to defrost breast milk.
Stormont Health Committee members asked where blame for failures lay, after the report also questioned the level of communication between health professionals and revealed two health trusts only heard of the death in Derry through the media.
Committee chair Sue Ramsey asked Professor Troop: "So if these systems had have been operating the way you believe they should have been operating, then this mightn't have happened?"
The report's author said: "I think if you'd had stronger systems, I think there are a number of things in here where, had they been in place, we might not be in this situation."
But Prof Troop said contamination in taps was a widespread issue and added: "But fundamentally though we mustn't lose sight of the fact that it was this consequence of other practices that put the pseudomonas in the taps in the first place - and that wasn't the failure of individual staff - that was a problem that has arisen across the country, the UK as a whole. It's then how you manage that situation."
Assembly members were highly critical of circulars alerting medical staff of infection issues, complaining that they did not go far enough in raising the alert, particularly after the death of the baby in Derry.
Ms Ramsey questioned the report finding that the Northern and South Eastern trusts revealed they were not aware that an outbreak of pseudomonas had occurred at Altnagelvin neonatal unit, prior to the declaration of the outbreak in Belfast on January 17.