An independent review published yesterday identifies the pandemic and the speed of decision-making in the midst of the pandemic as the “primary cause” of the crisis.

However, it says the crisis “could not have happened if the Department [of Health] and the RQIA had had the basics of good governance in place”, including “clear roles, well established and functioning relationships, clearly understood lines of communication, reporting and accountability”.

A heavily-redacted section of the 136-page report highlights the board meeting where members were advised of a pre-action letter received from KRW LAW in relation to a judicial review of the RQIA’s withdrawal of care home inspections.

The meeting “was a ‘light bulb’ moment for the Board as it highlighted the fact that the RQIA Board was accountable for decisions which it had not taken, been consulted on or necessarily agreed with”, the report states.

The Department of Health reinstated care home inspections a day after the resignations and KRW LAW subsequently withdrew the legal action.

Health Minister Robin Swann yesterday told MLAs: “I deeply regret that the Board members did not come to me and say they were on the brink of resigning. I would have taken that very seriously and I believe we could have worked together to resolve the difficulties.”

He added: “I have considered all the recommendations and can report that I have accepted them all. Since receiving the independent panel’s report in late January, my department has developed an action plan detailing my response. This is published today along with the report.

“I believe it is important that they are both published together. The process has taken longer than I would have ideally wanted, but pandemic related workload pressures have continued to seriously disrupt Departmental business.

“I can assure members that I want to ensure this situation does not happen again, in the RQIA or any other arms-length body of my Department. As the report highlights, there are lessons to be learned across government.”