TWO days before the publication of yesterday's damning report, the Department of Health released a review of how the Dunmurry Manor case was handled by regulators - concluding there had been "good practice" by inspectors.
For anxious families gathering in a Belfast hotel yesterday, the timing - the RQIA watchdog was also praised for "taking action to protect people"- had led to fears it was setting the tone for an investigation they had been waiting on for almost 18 months.
But within minutes of the Commissioner for Older People beginning his address, it was clear that his extensive probe had taken a radically different line, with one expert even stating that the north's inspection process is "not fit for purpose".
It also became apparent that it was not health authorities who had raised the alarm on a home that starved its residents, left them soaked in their own urine and used dirt-cheap incontinence products while its owners raked in huge profits.
The whistleblowers who were instrumental in getting the commissioner's shocking findings to print were not linked to any NHS body, but were instead two distressed families and two former staff members.
Despite the department's assurances, the commissioner's report is definitive in identifying serious failings in how the north's health service regulates care homes - with catastrophic consequences for the most vulnerable people in our society.
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Runwood Homes, the parent company of the Dunmurry facility, has accepted blame and its managing director stepped down - but this latest scandal comes just 10 months after another of its homes was closed down due to "serious risk to life" of residents.
Young women who are fighting for accountability following the sexual assault of their grandmother by a resident at Dunmurry Manor spoke yesterday of how they didn't want this to happen to another family.
Commissioner Eddie Lynch commended those families for their courage and was forceful in his calls for greater transparency.
Five months after the release of the hyponatraemia report and pledges of a more "open" culture, it is all the more disappointing that Mr Lynch said he faced "defensive" and "unhelpful" responses from NHS bodies.
In the foreward to the report, the commisioner quotes Mahatma Gandhi: "The true measure of any society can be found in how it treats its most vulnerable members."
It can only be hoped this report doesn't "sit on a shelf" and the health service heeds Gandhi's message to ensure such failings are never repeated.
