Main points
• Pat Joe Walsh's death from a bleeding ulcer, while it may have been inevitable, was avoidable in the circumstances in which it occurred
• Monaghan doctors were unable to arrange his transfer to Drogheda or Cavan hospitals even though there were critical care beds in both
• The failure of the on-call consultant in Monaghan to make direct phone contact with the on-call consultants in the other hospitals, or to consider transferring Mr Walsh by ambulance even though the other hospitals didn't want to take him, "fell short of good clinical practice"
• The unwillingness of surgeons in Drogheda and Cavan to immediately accept Mr Walsh was unacceptable
• There were serious process failures at almost all levels of activity apart from nursing care
• There has been continued failure by management over a sustained period to address factors that resulted in the failure to achieve Mr Walsh's transfer
• Ongoing difficulties in the relationships between individual consultants and between Cavan and Monaghan hospitals made a significant contribution to the environment that resulted in Mr Walsh's death
• All acute in-patient services at Monaghan hospital should cease at the earliest possible opportunity. It is essential that resources be provided to both Cavan and Drogheda to expand their in-patient capacity.
• It would be "unreasonable to close Monaghan hospital entirely".
• The treatment unit at Monaghan should become a nurse-led minor injuries unit, opening "office hours" only.
• The "events occurred not primarily as a result of individual clinician failures, but as a consequence of dysfunctional processes, relationships and management structures".
• The clinical care given to Mr Walsh in Monaghan on the night he died was beyond criticism. Mr Walsh was also properly treated in Drogheda.