A post-mortem should have been carried out on baby Bronagh Livingstone, the premature baby who died within hours of being born in an ambulance after her mother was refused admission at Monaghan General Hospital, according to an internal North Eastern Health Board report.
The report was compiled by the board's medical adviser, Dr Finbar Lennon, after it emerged that Ms Denise Livingstone (32) had been refused admission to the hospital and that her baby had died within hours of her giving birth during a 25-mile ambulance transfer to Cavan General Hospital.
The report from Dr Lennon, a surgeon at Our Lady of Lourdes Hospital in Drogheda, is separate from two other reports published on the Livingstone case on Friday night by the Minister for Health, Mr Martin.
One of those reports was compiled by the NEHB's risk managers, while the other was an independent review of the case by a three-person team appointed by the Minister. Given the critical nature of the independent review, Dr Lennon offered his resignation to the NEHB on Saturday but it was not accepted.
His report on the case, which was also sent to the Minister but not referred to by the independent review group, said: "Notwithstanding the fact that the family declined permission for a post-mortem and that the coroner was advised about the case, it would have been helpful in this instance had it been carried out."
In addition, he said, clinical notes and records on the care provided to Ms Livingstone at Monaghan General Hospital before she was transferred by ambulance to Cavan "may not have been completed in a timely manner".
However, Dr Lennon noted that the general care and attention provided to the mother and infant "was satisfactory and of a high standard".
He added: "The application of the transfer procedure was deficient in some respects but the necessity in the circumstances to transfer Ms Livingstone to an obstetric unit albeit in an advanced stage of labour was correct."
He also said it was his "considered opinion that in this particular case the decision to transfer this mother to Cavan was correct".
The independent review had said Ms Livingstone should not have been transferred.
In line with the independent review of the case, Dr Lennon felt that a nurse should have accompanied Ms Livingstone in the ambulance.
The NEHB's report published on Friday said the fact that a nurse had not travelled with her did not compromise the care of Ms Livingstone or her baby.
Nonetheless, it said, the reasons why a midwife did not travel when requested to do so by ambulance personnel "may require further investigation".
The midwife told the inquiry she was concerned about depleting staffing at Monaghan hospital and that she suffered from travel sickness in ambulances.