Major health trust failings in dealing with child protection cases have emerged in a review that followed the Omagh fire which killed a family of seven.
The blaze at Lammy Crescent in 2007 claimed the lives of Arthur McElhill, his partner Lorraine McGovern and their five children - Caroline, 13, Sean, 7, Bellina, 4, Clodagh, 19 months and James, nine months.
It is believed McElhill, a convicted sex offender, started the fire - prompting concerns over how the family were dealt with by various agencies.
The report released on Wednesday has claimed there were omissions, chaotic file keeping and too many acting managers within the Western Health Trust.
A total of 63 recommendations have been made in the report prepared by the Regulation and Quality Improvement Authority, which highlighted a number of deficiencies in key areas - including concerns about staffing levels.
'Delays'
The RQIA document said two offices were in charge of intervening with families.
In one a senior practitioner post was vacant and three agency social workers covered full-time vacancies.
In another there were two acting social work managers, two acting senior social work practitioners and three agency social workers.
"The robustness and the effectiveness of the gateway services was having an impact on the ability of the family intervention team to provide an ongoing service," it said.
"This was evidenced by delays in allocation of cases to a social worker in the family intervention team."
During this audit, 13 cases were identified where there were either current or historical concerns of a child protection nature. The trust has now satisfied itself that any child protection concerns are being appropriately managed.
Western Trust assistant director for family support Tom Cassidy said: "Although the trust can demonstrate significant progress in relation to the report's recommendations, the trust is not complacent about the complexity of the child protection environment and continues to take our responsibility very seriously.
"The trust has provided additional training for staff and strengthened the staffing arrangements within the teams reviewed."
Health Minister Michael McGimpsey said the failures to meet standards were not acceptable. He has written to all five trusts setting out the response he expects from them.
The reports also reflect the high levels of pressure on social services. In the past five years there has been a 24% increase in the number of referrals.
Mr McGimpsey said he had invested some £20m in 2008/09-2010/11 in child protection teams and family support services.
© Press Association