mr mcgurgan found that one nurse had added to her original account of what had happened on the ward on the morning of july 16, 2016 to state that "the cot sides were up".
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treatment delays are also causing needless anxiety and distress to patients as well as putting lives at serious risk.
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speaking after a four-day inquest, the family of brigid cavanagh, who died on july 20, 2016, said the western health trust should be ashamed after the 83-year-old had died in "terror".
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at least 9,000 rohingya were killed in rakhine state from august 25 to september 24, according to doctors without borders.
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