A health expert said the hyponatremia investigation revealed "lies, delusions and cover-ups" in healthcare.
Professor Gabriel Scally also said that the Ministry of Health could have saved the lives of some children whose deaths were investigated during the lengthy investigation.
The final report of Justice O & #; Hara found the death of four Northern Ireland children ̵
He also pointed to grave shortcomings that the Ministry of Health described as a source of "shame for all in health care".
Speaking to BBC NI, Professor Scally, a former senior NHS physician who was a consultant for the 14-year investigation, said the department should have had proper systems.
He said, "This is a remarkable account of lies, fraud and cover-up, negligence and fraud secrecy and deliberate obstruction."
The paramedic said that people "can not be held accountable" and that there is one "toxic" relationship between some health professionals in Northern Ireland.
"I've seen it before, but only in individual institutions or between individual teams," he said.
"It seems to have been a widely used pattern throughout the province."
Professor Scally added that the department could have saved lives if done right.
He said, "The Department of Health is not the health service, it is a department of the state, it is a department that serves and serves the people, which means holding the NHS accountable.
"They should have done that and it does not look as if they did."
He also called for Dr. Michael McBride, chief physician of Northern Ireland, to speak publicly about the matter and reassure the public, how improvements are made.
He added, "If it were me, I'd say I'm sorry this happened. I'll make it my job, for the rest of my career, to make sure that this never happens again.
"The senior physician, if involved, should talk about it and talk to the public. By talking to the families about what he has learned from them, and advancing the recommendations and driving change, he could very well be the best person because he knows them from the inside.
The Ministry of Health affirmed the errors highlighted in the report by Judge O & # 39; Hara.
Howe She pointed out that Justice O & Hara agreed that the health care environment since then had been reviewed by him Time has changed.
The Department said, "The 96 recommendations and other details of this work will be further elaborated in detail will be published in the near future.
"The latest update would have been published, but relevant staff were heavily involved in the department's response to the Belfast Trust Neurology recall."