A telephone call by an MP to a senior Department of Health official in August 2017 about abuse allegations at Muckamore hospital was a pivotal moment in what was to play out over the next 18 months.
A tussle for information was to emerge with the same department official doggedly asking questions of the Belfast trust as to what was going on in a regional facility for adults with the most severe learning disabilities.
By October 2017, frustration with the trust's handling of the Muckamore crisis led to an explosive letter being sent to its chief executive in which the department's chief social worker expressed his "considerable alarm" and branded failings in passing up information to government as "profoundly disturbing".
The correspondence, obtained by The Irish News earlier this year, gives an insight into how horrendous allegations involving incredibly vulnerable patients were initially handled by Northern Ireland's biggest health trust.
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The department has admitted privately to the father of a patient whose case sparked the major investigation that if he had not contacted his MP who then made that phone call then the magnitude of the crisis may never have come to light.
The latest decision by the department to reject the same man's call for a public inquiry is all the more disappointing given the concerns about transparency over the past year.
It also beggars belief that it has dismissed the public interest argument "at this time" for holding such an inquiry.
As this parent - who was forced down the Freedom of Information route to get answers about suspected abuse of his non-verbal son - asks in today's Irish News: "How bad does it have to get before a public inquiry is ordered".
With the National Crime Agency now involved and the PSNI seeking to increase its resources to deal with the scale of the allegations, a judge-led independent inquiry would appear to be the only way to get to the truth.
