Editor's Viewpoint: Report diagnoses only the symptoms
The final report into the deaths of four babies from pseudomonas infection at Northern Ireland hospitals, unsurprisingly, has blamed poor communication between health trusts and officials for the spread of the outbreak.
Warnings about the infection were not explicit enough and the reaction of trusts was not urgent enough. Also unsurprisingly - and as suggested by this newspaper some time ago - no one was held accountable for the failings, there were no suggested sanctions and there was the usual line of lessons having to be learned.
There were, however, criticisms of the role of the Media, although it was pointed out that some trusts only learned of the original outbreak at Altnagelvin Hospital in Londonderry through media reports.
The media is often an easy target and the Leveson Inquiry into concerns about Press intrusion provides ready ammunition for critics. But - even as this case shows - it is only by the Media shining a light into dark corners that some issues get aired at all.
And nowhere is that more apparent than in this province. There is a pervasive culture here - a need to know culture - which limits information to certain select groups of people. They abhor transparency or the public release of information. That was the real root of the problem in this case.
If there had been clear, concise and public information about the death of the first baby in Altnagelvin then there would have been no excuse for other health trusts not knowing of the potential danger of the infection lurking in taps in the neonatal units of a number of other hospitals.
Sadly this report does not highlight this secrecy culture, instead concentrating on imprecise internal communications, which are but a symptom of the problem.
As the Leveson Inquiry continues on its grinding path, there will be many calling for new controls on the Media when what is really needed is open information systems which keep the public informed of the issues that affect their daily lives.
But how likely is that, especially here?