The long-awaited Leas Cross report has concluded that care at the nursing home was deficient at many levels and consistent with a finding of institutional abuse.
The report by consultant geriatrician Prof Des O'Neill, which was published by the Health Service Executive (HSE) earlier this afternoon, is highly critical of poor standards of care at Leas Cross and of the role of the HSE and the former Northern Area Health Board.
It claims that although there is a statutory obligation on nursing homes to report all deaths to the HSE or in the past to health boards, not all deaths at Leas Cross in Swords were reported to the health authorities.
Moreover, the document claimed that there is an almost complete lack of monitoring of deaths in Irish nursing homes. It also criticises the level of medical and nursing cover at Leas Cross.
According to the report, there was no evidence of any vocational training for care any of the care assistant staff in the nursing home and no policy proffered for ensuing such training.
Prof O'Neill's report said that the deficits in care shown in Leas Cross are very likely to be replicated in other institutions throughout Ireland due to a lack of structure, funding, standards, and oversight.
The document stated that "urgent action was needed to remedy system failures so as to ensure that vulnerable older Irish people can be confident that they will be cared for in a safe and caring environment with an optimal quality of both life and care".
Publication of the Leas Cross report was delayed for several weeks because the HSE insisted on allowing submissions from individuals mentioned in the text.
The HSE has said it fully accepts the recommendations made by Prof O'Neill and has already made many improvements to its nursing home inspections process over the last year. These include a new national training programme for inspection team members, the hiring of 32 Elder Abuse Officers and the publication of inspection reports on its website.
Aidan Browne, National Director for Primary, Community and Continuing Care services said the quality of care provided to residents in a nursing home is the responsibility of the nursing home owner.
"As well as the specific issues identified by Prof O'Neill, the HSE believes that many of the problems experienced by nursing homes are associated with the absence of an appropriate continuum of care in many circumstances," said Browne.
Following the publication of the report, the former chief executive of the Northern Area Health Board (NAHB) said she deeply regretted that a number of patients at Leas Cross were injured during their residency.
The north Dublin nursing home was shut down in July 2005 following an undercover RTÉ investigation. Secret cameras showing the treatment of patients caused a public outcry, and the Dáil heard calls for strict regulation of the sector.
Residents were later transferred to other homes, and Ms Harney commissioned the report by Mr O'Neill.
Copies of the report have been sent to the Garda, the Medical Council and An Board Altranais to decide if there are any issues to be pursued