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"we have to thank the coroner and his office for the work they have done. they have clearly listened to all of the evidence and came to the conclusion the family had all along. .
"there is an issue that needs to be addressed in terms of the narrative the health trust tried to present and mislead the inquest and cover up what actually happened. .
"their serious adverse incident process has been wholly inadequate and what we have heard this week is a damning indictment of the western trust.
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