It points to the lack of a culture of openness where one doctor carried too heavy a workload and where consultants imposed too much of their personality on the maternity unit.

The inquiry was also "unimpressed by the unwieldy bureaucracy" of the health system.

It was "equally disturbed that provincial hospitals are not expected to provide the same level of care as the Dublin training hospitals".

While the report acknowledges that the Lourdes maternity hospital is "unrecognisable" since 1998, it concludes that the hospital is "bursting at the seams and is often seriously overcrowded". Among the recommendations in the report are the requirement for peer reviews, clear management structures, greater sharing of medical data between all maternity hospitals, and the introduction of a legal obligation on medical personnel to keep their skills updated.