The McColgan children could have been spared much of the suffering they experienced at the hands of their father, Joe McColgan, had the health board collated all the information in its possession and used it as the basis for legal action to take the children into care.
This is the conclusion of the review group which has been examining the North-Western Health Board's involvement in the case. Joe McColgan is serving a 12-year sentence for physically and sexually abusing his children.
In its response the board has honestly acknowledged that, had certain actions been taken by its officers and senior staff in the mid-1980s, the McColgan children could have been spared years of suffering. It also apologised to the now-adult children for its failings.
This is in marked contrast to the stance it adopted during the court case late last year, which continued into January, in which several days were devoted to arguing, effectively, that the damage suffered by Ms Sophia McColgan was minimal and that she had been able to conduct a perfectly normal life.
The legal strategy pursued by the health board, and supported by lawyers for the family doctor also sued, Dr Desmond Moran, was to argue that the Statute of Limitations applied. This was an argument that the case should be thrown out on the grounds that Ms McColgan should have taken her action within three years of her majority - two years of which she had spent being physically and sexually abused by her father.
She argued that she was so damaged by some 15 years of torture and abuse that she was in no state to confront what happened to her, let alone brief a solicitor and pursue a legal case.
Counsel for the health board, Mr John Rogers SC, put it to her that she had gone to college, got a degree and a job, established a relationship and was rearing a child, so that clearly she was in full possession of her faculties and could pursue a case.
Although sometimes reduced to tears, Ms McColgan insisted that it was not until she had received counselling that she was able to face what had happened to her, from which she had still not fully recovered. Evidence by several experts was called to support this.
It was clear during the case that various health board personnel involved, and present in court, were not comfortable with this strategy, and were hugely relieved when the case ended in a settlement.
It has since emerged that it was not the health board which was responsible for the legal strategy, but its insurers, Irish Public Bodies Mutual Insurances Ltd.
Following the settlement of the case without admission of liability, the Minister for Health told the Dail that the board had been bound by a clause "which gives the sole control and conduct of all claims to the insurer . . . I understand it was the insurer who dictated the strategy adopted."
Irish Public Bodies Mutual Insurances Ltd was set up by statute in 1926 "to secure economy in the insurance expenditure of local authorities." It provides "a comprehensive risk management service to its members."
Lawyers for the board also argued during the case that, given the state of the law relating to child protection at that time, there was nothing more it could have done. It was dangerous to view the events of the early 1980s from the perspective of the 1990s, they said.
While this is acknowledged by the review group, they did find that the board did have the legal means at its disposal to take action to protect the children, had the management co-ordinated its response to the evidence of abuse, marshalled all the information and properly briefed lawyers.
The report did highlight the improvements which have taken place since.
These include the implementation of the Child Care Act, the allocation of additional resources amounting to £2,614 million between 1993 and 1998, the implementation of new guidelines for the reporting and investigation of child abuse cases, more training, and the introduction of an audit and evaluation system.
It remains to be seen whether all this is sufficient to ensure that no more cases will be taken against public bodies for failing to protect children at risk - and whether, if it happens, they will again invoke the Statute of Limitations to avoid liability.