Justice O'Hara found that:

while investigating the death of Adam Strain, the inquiry had been met with "defensiveness and deceit" and that "information was withheld" about what happened to Adam in the operating theatre

there "was a cover up" in the death of Claire Roberts, whose death was not referred to the coroner immediately to "avoid scrutiny"

poor care was "deliberately concealed" in the death of Lucy Crawford

there was a "reluctance among clinicians to openly acknowledge failings" in the death of Raychel Ferguson

in the death of Conor Mitchell, there was a "potentially dangerous variation in care and treatment afforded to young people at Craigavon Hospital"

In total, the inquiry made 96 recommendations including the establishment of a duty of candour on medical professionals "to tell patients and their families about major failuresin care and to give a full and honest explanation".

Media playback is unsupported on your device Media caption The chair of the hyponatraemia inquiry believes evidence was withheld about Adam Strain's death

Mr Justice O'Hara added that the "reticence of some clinicians and healthcare professionals to concede error or identify underperformance or colleagues was frustrating and depressing".

Marie Ferguson, the mother of Raychel, said that the inquiry was "confirmation of what we knew happened".

Image caption Marie Ferguson, the mother of Raychel, during the delivery of Mr Justice O'Hara's findings

"She went into hospital as a young, healthy girl and was neglected by the nurses, neglected by the doctors and, ultimately, died because of the negligence of those we consider health professionals."

Mrs Ferguson added that she had been devoted to finding the