Inadequate communication, breakdowns in working relationships and deficiencies in governance were behind the mass resignations at the care home watchdog last year, an independent report has found.
Nine board members at the Regulation and Quality Improvement Authority (RQIA) resigned last June over claims they were not consulted on key decisions taken during the coronavirus pandemic.
Health Minister Robin Swann then ordered an independent review into the situation.
The RQIA played a key role in the struggle with Covid-19 which, the review found, created severe and unprecedented pressures.
It added that, "whilst understandable", the resignations "were not necessary or desirable, particularly during a time of crisis".
Mr Swann welcomed the conclusion of the report.
"I deeply regret that the board members did not come to me and say they were on the brink of resigning. I would have taken that very seriously and I believe we could have worked together to resolve the difficulties," he said in a written statement to the Assembly on Monday.
However, he said the review team was "also clear that the Department of Health cannot escape its share of responsibility for what occurred".
"It believes that, if better governance had been applied between the department and RQIA, this event may have been averted," he said.
"The recommendations put forward, therefore, are aimed at providing the necessary clarity on roles and responsibilities and relationships for a minister, for his or her officials, and for the department's arm's-length body (ALB) boards, along with their executive teams, in accordance with legislation and best practice."
The review team made a number of recommendations to address the lack of proper working relationships, ensuring that the governance approach is in line with best practice and appropriate communication channels, with clear roles and responsibilities.
Mr Swann added: "I am pleased to report that a number of early actions I initiated since becoming minister in January 2020 go some way to addressing key issues. These include the establishment of regular meetings with the chairs of all arm's-length bodies, including RQIA.
"I have considered all the recommendations and can report that I have accepted them all.
"Since receiving the independent panel's report in late January, my department has developed an action plan detailing my response.
"This is published today along with the report. I believe it is important that they are both published together. The process has taken longer than I would have ideally wanted, but pandemic-related workload pressures have continued to seriously disrupt departmental business.
"I can assure members that I want to ensure this situation does not happen again, in the RQIA or any other arm's-length body of my department.
"As the report highlights, there are lessons to be learned across Government."