(1) The Health Service Inquiry Officer appointed to conduct a Health Service Inquiry must prepare and provide a report to the System Manager in relation to the Health Service Inquiry.
(2) The report may make recommendations in relation to any of the following:
(a) the administration or management of the relevant Service;
(b) the performance of the Service in providing health services.
(3) After considering the report, the System Manager may:
(a) take the action the System Manager considers appropriate (including issuing a Health Service Directive); and
(b) make the report available to the Board and the COO for the relevant Service to improve the provision of health services by the Service.