A process whereby an external investigation is conducted on behalf of a state body and then subjected to further probes by the chair of the body in question is highly unusual

Inspector became aware  adjustments originally requested had been made by somebody else for final report

The newly-published terms of reference say senior counsel Lorna Lynch should consider six aspects of roughly 300 case files to determine whether anything meriting disciplinary action took place

The care plan for a mother whose baby boy died less than two days after his birth was “not clear”, an inquiry heard yesterday.