In its report into the Baby Bronagh Livingstone death, the North Eastern Health Board concluded that the decision to transfer to Cavan General Hospital was the right one, given the condition of Ms Denise Livingstone and the "prevailing conditions on both sides".
The report's summary says: "Following this incident the Minister for Health and Children requested that the board carry out an urgent investigation and subsequently indicated that this report would be evaluated by an external independent expert group appointed by the Minister.
"In preparation for this external review team the CEO of the NEHB requested the corporate risk manager to conduct a review of the facts relating to this incident.
"This initial review was carried out by the risk adviser of Louth Meath Hospital in association with the corporate risk manager on the 13th-14th December.
"This review consisted of interviewing persons directly related to the incident and their line managers and a review of related policies and correspondence.
"Monaghan General Hospital operates a 24-hour treatment room for the treatment of walk-in patients. Patients who self-attend at the treatment room and whose condition is beyond the capabilities of the hospital to treat are stabilised and transferred to the nearest appropriate hospital.
"Since July 2002, patients who access ambulance services from the community (i.e. via 999 call) are taken to the nearest appropriate hospital depending on the nature of their condition as Monaghan General Hospital has been off call since then.
"Following the suspension of obstetrical services in Dundalk and Monaghan in March 2001 the NEHB recognised the need to have in place a procedure to address the eventuality of a pregnant woman attending in labour or requiring admission at any of the NEHB hospitals that do not have an inpatient obstetrical service.
"The review considered the statements and interviews held with staff associated with the incident and looked in particular at the robustness of the procedure in place to deal with such incidents.
"The reviewers concluded that the decision to transfer to Cavan General Hospital was the right one given the condition of the mother and the prevailing conditions on both sites.
"The reviewers also feel that in this case the outcome to mother or baby was not compromised by the absence of a midwife during the transfer.
"However, a series of shortcomings were identified and these are outlined in the report."
The shortcomings pinpointed in the report include:
• The "significant" failure of the surgical senior house officer in Monaghan to inform his consultant of the situation.
• The surgical doctor on call at Monaghan contacted the obstetrical senior house officer in Cavan rather than the labour ward.
• The obstetrical senior house officer in Cavan should have redirected the phone call to the labour ward in Cavan.
• Despite Denise Livingstone being less than 32 weeks pregnant, Our Lady of Lourdes Hospital was not contacted about advice and treatment.
• There was no decision for clinical personnel to accompany Ms Livingstone, as this was not discussed between the doctor and the nursing staff. However, at interview all clinical staff involved seemed to indicate that the medical needs were great and the situation was serious.
The report says there was a deficit of staff knowledge and a lack of senior clinical leadership.
"This meant that the decisions around the management and transfer of this woman fell to two senior house officers and a staff nurse."
The report also says there was "poor team working" between the senior house officer and the staff nurses.