The Health Service Executive admitted yesterday that the terms of reference it set for a review of deaths at the Leas Cross nursing home should have been different.
Last year it commissioned Prof Des O'Neill, a consultant geriatrician at Tallaght hospital, to review all deaths either at the north Dublin nursing home or immediately after transfer from the home between 2002 and 2005. He was asked to do this by reviewing documents only and his final report, which was sent to the HSE last May, has still not been published.
However, Prof O'Neill has said his findings were grave, disturbing and in need of urgent attention, though he did not find any of the deaths were preventable.
The HSE, under criticism for not publishing the review, has claimed its legal advice is that it cannot be published because people named in the report were not given an opportunity to respond to criticisms of them.
It asked Prof O'Neill to revisit his report to do this. However, he said that if he were now to hear oral and written submissions it would be akin to the setting up of a tribunal of inquiry.
Yesterday HSE chief executive Prof Drumm said: "Well I think to be fair to Prof Des O'Neill he was given a very difficult task because he undertook this report over a short period of time based on a review of the documentation that was available in relation to Leas Cross. What he wasn't asked to do - and perhaps in retrospect this was an error - was to interview the individuals involved which would be a much larger process and one for which he would have needed an awful lot more supports."
He told the This Week programme on RTÉ radio: "I think if we were actually starting again that we would accept that we would have put in a broader review process."
Prof Drumm said he expected to see the review published at some stage. Minister for Health Mary Harney has sought the advice of the Attorney General on whether the report could be published through the Oireachtas, in which case it would be covered by Dáil privilege.