It is a 230-page tale of complacency, poor planning, questionable maintenance, lack of communication or adequate responses and seemingly general ineffectiveness in providing safe drinking water.
The first stage report of the Havelock North Drinking Water Inquiry certainly did not hold back in its criticism of the Hastings District Counciland the Hawke's Bay Regional Council, while the District Health Board seemed to come out okay.
The 2016 gastro crisis was a big deal - a third of Havelock North residents were laid low and lives were lost. The report found that a higher standard of care and diligence had been needed to protect public's health.
In releasing the findings yesterday, inquiry panel chairman Lyn Stevens QC said failings on the part of the two councils did not directly cause the outbreak, but there may have been a different outcome without those failings.
It is a very comprehensive report and does not paint our councils in a very good light.
Although they may have escaped the ultimate censure, both councils' processes and methodology before and in response to the crisis are harshly criticised.
A stark point in the report is that it seems as if important decisions regarding water protection and supply were being made by mid to lower level Hastings District Council officials. Where were the highly paid senior council managers and where was the oversight from our elected council?
It is also astounding that the many warnings and lessons were not heeded and learned by both councils.
The regional council also needs to reflect long and hard on its handling of things and the way it appeared to try to lay all the blame at the district council's door.
Both councils should realise that even though they were officially found not to have directly caused the outbreak, they still failed and need to do better - much better.
