In its report, Mr Law said the initialcase, reported to a ward sister on the 30 November 2009, should have been raised with senior staff at the hospital because a more "robust approach" may then have been taken.
No talks have taken place since March 11, with lawyers for each side focusing on the initial decisions of a case that has turned labor law on its head.
In each case, the initial rush to judgment by law enforcement and the media may have distracted officials from the real perpetrator and caused unnecessary harm to individuals and ethnic groups who had nothing to do with the attacks.