Editor's Viewpoint: Who will carry the can for the deaths?
The interim report into the pseudomonas outbreak in which four babies died confirms what this newspaper has argued from the outset - that a chronic lack of communication between health officials contributed significantly to the scale of the problem.
Indeed it should be remembered that the initial death of a baby at Altnagelvin Hospital in Londonderry only became public knowledge because the parents contacted the media. What all the parents will now have to live with is the fact that better communication could have saved the lives of some of the babies.
How the situation was allowed to develop is puzzling. After the death in Derry just before Christmas a specialist team which met in Belfast did not intend to meet again until January 24.
And while the Western Health Trust agreed the use of sterile water for washing babies in Altnagelvin Hospital's neo-natal unit, the Belfast Trust did not follow suit until quite a number of infants were infected.
Northern Ireland's neo-natal network is small and adopting common approaches and sharing information should not be a herculean task.
Quite rightly the interim report is critical of the lack of co-ordination and it has made 15 recommendations to improve matters. Yet parents will wonder if this will just be the usual mantra of lessons being learned but no one being held to account for the obvious shortcomings in the system, which had lethal consequences.
In fairness to Health Minister Edwin Poots he has promised to implement all the recommendations and has met with the bereaved parents to discuss the report's findings. His humanity is not in question, but will he also show the required steel to bring leading health officials to book over the deaths? If any good can come out of these deaths, it should be that systems are improved, important matters of public health are not kept secret and people are made responsible for their actions, or in this case, inactions.