The preliminary report of an independent inquiry into the death of a man who bled to death at Monaghan General Hospital last October has found "systematic evidence of serious process failure" at several levels in the hours before his death.
Pat Joe Walsh (75) from Killanny, Carrickmacross, Co Monaghan, died after doctors failed in their bid to have him transferred to two other hospitals in the region - Our Lady of Lourdes Hospital in Drogheda and Cavan General Hospital - for emergency surgery.
The transfer was sought as doctors in Monaghan were not allowed carry out emergency surgery. They were told Drogheda and Cavan hospitals had no intensive care beds available for Mr Walsh. It later transpired this was not the case.
The inquiry has found that: "Despite repeated requests using appropriate telephone communication the Monaghan doctors were unable to arrange the transfer of Mr Walsh to either OLOL [ Our Lady of Lourdes Hospital] or Cavan hospital although there were critical care beds available in both hospitals."
It also found "the refusal of surgeons in both OLOL and Cavan hospitals to accept Mr Walsh's transfer was unacceptable and also fell short of good clinical practice".
And it criticises a lack of consultant-to-consultant contact between the hospitals on Mr Walsh's possible transfer.
"The inquiry has revealed systematic evidence of serious process failure at almost all levels of activity apart from nursing care. This process failure resulted in an inability to achieve transfer of the patient," the report states.
It continued: "The reviewers recommend most strongly that this is an opportunity for all the relevant stakeholders to pause and ensure a clear refocusing on the core values of patient care. The inquiry has revealed evidence that continued disputes of an interpersonal and 'political' nature have resulted in a loss of this basic perspective."
The report has not yet been published but The Irish Times has seen an extract from it.
Consultant surgeon at Belfast City Hospital Declan Carey conducted the inquiry and was assisted by Prof John Monson, professor of surgery at the University of Hull.
They submitted their preliminary report to the HSE last month and extracts were circulated to those referred to for their comments.
Responses made before June 20th will be considered before the final report is submitted to the HSE.
Last night Edward Walsh, a nephew of the dead man, said he had not seen any of the report and was disappointed the family had not received a copy of it before it was circulated to third parties.