FOR the woman whose testimony to the Haslam-Kerr inquiry was imperilled, it was "incredible". We might add astonishing, even scandalous. Whichever word you choose, the failure to offer witnesses legal protection from the outset was a spectacular blunder.

The victims had been waiting a long time for this inquiry. Offences committed by the two retired psychiatrists, Michael Haslam and William Kerr, were dealt with by the courts decades after they took place.

These hearings raised serious doubts about how the NHS responded to complaints about the doctors' behaviour. An inquiry was imperative. Eventually, the then Health Secretary Alan Milburn agreed.

Fully three years after he ordered the inquiry, the hearing began earlier this month - only to be gravely undermined when witnesses learned their evidence could leave them open to be sued for defamation.

What madness. The purpose of the inquiry is to get to the truth. All witnesses must feel able to offer full and honest testimony, without fear. That becomes impossible if they believe their words could land them in court.

These women had summoned up exceptional courage to relive their ordeals for the greater public good. Then they learned that the inquiry had not afforded them the most basic safety net.

This is an even more disgraceful oversight when you consider that the Government overruled a strong campaign for a public inquiry partly because it believed witnesses could speak with greater frankness behind closed doors.

Health Secretary Dr John Reid is said to have only grasped the urgency of the problem when contacted by Phil Willis MP. Now the minister has issued legal indemnity for witnesses.

Finally the right decision was taken - but only after these women had been let down by blinkered bureaucracy.

Updated: 10:14 Wednesday, June 23, 2004