MINUTES after Mr Justice O'Hara had detailed his shocking findings in the Crowne Plaza hotel in Belfast, a wail echoed through the function room as a senior health official attempted to shake the hand of a grieving mother.
Visibly distressed, the woman broke down in tears while another family member had to be restrained as accusations were hurled about failings in their child's case.
Nearby, a weeping relative almost fainted and was helped to a chair.
The distress and anger felt by family members was understandable, having spent the previous 30 minutes quietly listening to the High Court judge detailing the scathing conclusions of the hyponatraemia inquiry.
Initially restrained in his delivery, he spoke in the harshest terms about a culture where parents were "deliberately misled" by some consultants and health service managers who were more concerned about protecting their reputations.
In his closing comments to a hushed room, the inquiry chairman's composure then shifted and he described in personal terms how he "couldn't imagine" how families felt.
In language not normally associated with such inquires, the judge spoke of his frustration with health professionals who had to have "the truth dragged from them" during hearings held in Banbridge.
Gareth Roberts, whose nine-year-old sister Claire died in the Royal Victoria Hospital for Sick Children in 1996 just two days after being admitted with a vomiting bug, said he was glad "the truth had come out" and called for new police investigations into the deaths.
"We have been living with this for 22 years. If it wasn't for my dad Alan and the way he kept fighting... I just want natural justice. We had so much love for Claire."
An emotional Marie Ferguson said she was glad the failings around her nine-year-old daughter's death had been made public and called for a new law compelling medics to be honest to be named in her little girl's memory.
Mr Justice O'Hara found that Raychel's death 17 years ago was "avoidable". The primary five pupil suffered brain death as a result of hyponatraemia, just 48 hours after she had won a medal at her school sports day.
"They robbed me of the most precious wee girl in my life... she was a healthy nine-year-old who suffered immensely in her final hours." she said.
The family of Conor Mitchell (15), who had cerebral palsy and epilepsy and died in Belfast after initially being treated in Craigavon Area Hospital, also said medical staff had "failed Conor so badly".
"The reticence with which the investigation has been handled by the trust and their advisers and the grudging way in which the limited acceptance of failings and minimal apology given were extracted, indicates a reluctance on their part to undertake the learning and the change in attitude needed to reduce the trauma caused in cases such as these," they said.
