Dr Steve Austin, the Southern Trust’s medical director, said the trust wanted to apologise to the affected patients and their families.
“What we’ve done is that actually we’re looking to make sure the processes in place today actually work,” he said.
“So we’re making sure that concerns are addressed promptly, that changes are put in place, recommendations from investigations are put in place.
“We monitor and track those very carefully to make sure they’re put in place to improve care.
“So I certainly know today the system is greatly different and it is working.”
In a joint statement, the Health and Social Care (HSC) system leaders said their thoughts are with the patients and families impacted.
“The inquiry focused on patient safety and these recommendations will help all Trusts in Northern Ireland avoid repeating past mistakes to ensure that other patients do not suffer harm.”
The Patient and Client Council said it welcomed the inquiries findings.
“In particular we recognise and support the finding that ‘the evidence presented demonstrated how listening to patients can give rise to meaningful learning about quality’ and crucially that ‘unless the involvement of patients becomes more embedded in the way systems operate, then it is likely that change may continue to be inadequate,” chief executive Meadhbha Monaghan said.
The inquiry did not determine criminal or civil liability or make findings on fitness to practice.
It examined how that harm occurred, why it was not fully recognised, and what changes are required to ensure safer care in the future.
It finished gathering evidence two years ago after hearing from 75 witnesses and receiving 650,000 pages of written evidence.
Aidan O’Brien was referred by the GMC for a hearing at the Medical Practitioners Tribunal Service (MPTS), for a tribunal to hear all the evidence, and make an independent decision about the doctor’s fitness to practise.
This process is still ongoing.
The inquiry recognised that improvements have been made since these issues came to light, including changes within the trust and wider work led by the Department of Health.
But it said it is clear that further, sustained and transformational change is required.
