It is alarming to think that were it not for the persistence of one parent, the scale of the appalling abuse at Muckamore Abbey Hospital might never have been uncovered.
Dundonald man Glynn Brown demanded to see CCTV footage following reports that his son, Aaron, was allegedly assaulted in August 2017.
Thanks to his refusal to give up, it was discovered that the cameras, which had been running for some time without the knowledge of staff or management, had recorded shocking conduct that has led to the biggest criminal adult safeguarding investigation of its kind in Northern Ireland, if not the UK.
This week saw the publication of a review into the leadership and governance of the Co Antrim hospital.
The authors of the review did not hold back in terms of their assessment of the management team, which was riven with tensions, personality clashes and animosity.
It also found there was a lack of interest and passion at trust headquarters in Belfast, with 'infrequent' visits by those in charge of the hospital which appeared to be 'a place apart'.
''Clearly, it operated outside the sightlines and under the radar of the Trust,'' said the report.
What is particularly troubling is that allegations had previously been raised about the all-female Ennis Ward in 2012, the findings of which were leaked to The Irish News last October and which exposed appalling mistreatment of patients.
The review team considered Ennis to be an example of 'institutional abuse' but there was a missed opportunity to learn from it.
There are many failings identified in this report which goes much further than previous investigations and the health minister and recently-appointed Belfast Trust Chief Executive have issued apologies.
But it is also clear that the scandal that has engulfed Muckamore requires a much wider and more powerful process that can ensure complete transparency and full accountability.
While welcoming the review as a step forward, Mr Brown expressed concern at the lack of cooperation from senior officials and explained that is why a full public inquiry is needed.
He is right.
The Muckamore patients, extremely vulnerable individuals who have very little voice in all this, were entrusted into the care of our health service, which has let them down.
Their families are speaking for them.
Robin Swann must listen to them as it is only a public inquiry that will uncover the full truth and send out a message that what went wrong cannot be allowed to happen again.
