There is an almost complete absence of systematic monitoring of deaths in Irish nursing homes, according to the independent review of deaths at the Leas Cross nursing home in north Dublin.
The review is to be finally published by the Health Service Executive today.
The report, compiled for the HSE by Prof Des O'Neill, says it is of concern that no governmental or health agency knows the death rates in Irish nursing homes.
It also says that while 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.
A total of 105 deaths between 2002 and 2004 were the subject of the review.
However, rather than delving into each of these individual cases, the report focuses on overall issues which caused concern, such as nurse staffing levels and lack of trained care assistants.
Prof O'Neill's report states that a number of complaints to health service management about the home did not trigger an appropriate response. These included complaints from doctors at St Ita's hospital in Portrane in 2004. They were concerned about the number of patients who died after being transferred from St Ita's to Leas Cross.
Criticism is also directed at the Department of Health and the Government. The report says that 23 years after a report called The Years Ahead was made official health policy, its recommendation for an independent inspectorate for residential care remains unfulfilled.
However, an independent inspectorate has been promised by the current Minister for Health, Mary Harney.
The report also says that with a few honourable exceptions, there has been a systematic failure by governments, health authorities and professional bodies to address the issue of appropriate quality of care for those older people with the highest levels of health and social need.
The report was completed by Prof O'Neill approximately five months ago but the HSE has claimed it was unable, on legal advice, to publish it until those clearly identifiable in it had been given time to respond to criticisms. Their responses are to be appended to the published report.
It is understood individuals have not been named in the report. However, they may be named in the submissions they have now made to the HSE in response to comments made about them in the report.
Prof O'Neill, a consultant geriatrician at Tallaght hospital, is already on record as saying his findings were grave, disturbing, system-wide and in need of urgent attention.
When part of his report was read into the Dáil record by Fine Gael leader Enda Kenny last month, he told TDs that overall the findings were consistent with "institutional abuse".
Leas Cross closed in August 2005 after the HSE withdrew public patients following a Prime Time Investigates programme.