The North Eastern Health Board has come under pressure to state why it did not address safety issues at Cavan General Hospital highlighted in a report presented to it three years ago.
The report, from its external risk advisers, Healthcare Risk Resources International (HRRI), warned there were no clinical policies for admitting, transferring or discharging patients in A&E.
It also referred to poor teamwork across most specialties, and the fact that A&E space and staffing posed a risk to patient safety. In addition it said some areas of clinical practice were "adversely affected by poor management systems".
The report was released under the Freedom of Information Act, over a year ago, to former health-board member and Louth Fine Gael TD, Mr Fergus O'Dowd, but he said yesterday he decided not to release it until he read the more recent report into the death in February of nine-year-old Cootehill girl, Frances Sheridan, 36 hours after she was sent home from the hospital's A&E unit, presumed to have a tummy bug.
She had undergone an appendix operation at the hospital three weeks earlier and as her wound healed she developed adhesions, which resulted in her bowel becoming obstructed.
However, she was not referred to the surgery team when she was sent back to A&E by her GP, three weeks after her surgery, with severe abdominal pain. Her GP had sent her with a letter to the surgical team on call at the hospital, but the letter was not passed on.
She was seen only by two junior doctors in A&E, her file could not be found, and her GP was not told when she was discharged after an X-ray. Furthermore, the doctors in A&E had reservations about contacting the surgical team because they viewed them as unco-operative.
The health board blamed an absence of protocols and systems failures for what happened.
Mr O'Dowd said he decided details from the HRRI report should be published and he passed it to the Sunday Independent after he realised the shortcomings detailed in it were still problems for the hospital at the time of Frances Sheridan's death. They had obviously not been addressed in the intervening period and the buck rested with the Minister for Health, Mr Martin, he said.
Asked why it did not act on the HRRI report, the health board said yesterday it was making "no comment on the report today".
A Department of Health spokeswoman said the Department would immediately be discussing the issues which had been raised in the HRRI report with the North Eastern Health Board.
Mr Martin met the chief executive of the NEHB, Mr Paul Robinson, last week to discuss the report into the death of Frances Sheridan. He was assured a number of the report's recommendations had been implemented and others were in the process of being implemented. They are due to meet again shortly.