A report into the death of a Romanian-born child and the serious injury of his twin brother has criticised health and hospital authorities in the North.
Former overseas Christian missionary Geoffrey Briggs from Portadown was jailed for injuring one baby. The report said police should re-examine the circumstances and possible causes of the death of the other.
The independent report condemned a failure of the authorities in the north to properly monitor the children once they arrived, failure to monitor the inter-country adoption process diligently, and the confusion over who was responsible for what and a lack of leadership.
Three months after the twins' arrival in Northern Ireland, David was taken to the Craigavon Area Hospital by ambulance and declared dead on arrival. He was buried after a post-mortem that failed to determine the cause of death.
Just 13 days after he died, Mr and Mrs Briggs took his brother, Samuel, to the accident and emergency unit of the same hospital and he was found to have a fractured skull and other injuries.
Mr Briggs admitted punching Samuel and was charged with inflicting grievous bodily harm and sentenced to 12 months in jail. On his release Briggs left the north and Samuel was placed for adoption with another family.Following the injuries to Samuel, the coroner ordered the exhumation of David's body and a study of original X-rays. They showed he had suffered multiple fractures to his ribs and body - some 16 in all - prior to his death, which were not accidental.
The coroner is currently awaiting reports from the police and the British Director ofPublic Prosecutions before holding an inquest into the death.
The report made 39 recommendations for improving services and Northern Ireland Health Minister Angela Smith said she was accepting them all.
PA