The unpublished report at the centre of the latest Leas Cross controversy was commissioned by the Health Service Executive itself. It was a review of the circumstances of the deaths of 95 patients at the Leas Cross nursing home between 2002 and 2005 and it was carried out by one of the country's leading geriatricians, Prof Des O'Neill. But ever since he landed his report on their desks last May, the HSE has been acting like it was a grenade with the detonating pin removed.

Just last Thursday, HSE chief executive Brendan Drumm again repeated to an Oireachtas health committee that "legal advice" meant the O'Neill review couldn't be published "in its current form" because all staff in the health service . . . as well as those in Leas Cross . . . were entitled to "due process"; in other words to have the right of reply.

So what did the report say about these 95 deaths?

According to Prof O'Neill, the review actually finds that none of the 95 deaths was preventable . . . but significantly, it is highly critical of the lack of action over warnings from clinical practitioners about Leas Cross, and also expresses grave concerns about the wider system of monitoring and accountability in nursing homes for the elderly.

When the report was not published, O'Neill issued a statement saying "these concerns were grave, disturbing and system-wide and required urgent attention".

So will it be published at all then?

The HSE's national director of primary community care and continuing care, Aidan Browne, argues the body wants to publish . . . but can't because it will be damned in the courts by the individuals who are criticised.

"We are currently discussing with O'Neill how we may progress beyond the current situation, given this legal advice, and we're very grateful for his work so far, " says Browne.

The Minister for Health, Mary Harney, says it is "unacceptable" to her that the report goes unpublished. "We must learn in Ireland that any time you don't come out openly and transparently on issues you make problems worse; you don't solve them."

Behind the scenes, negotiations are going on and O'Neill and the HSE were meeting last week. O'Neill argues he's not some quasi-legal tribunal judge and his terms of reference never covered calling people in to account for themselves.

Does that mean that the problems Prof O'Neill has outlined are continuing with the obvious dangers to elderly patients?

The HSE insists this is not the case . . . it has learned the lessons of the review and it says its own inspection teams and standards have already been improved to take account of criticisms.

The trouble is, with no independent inspectorate of systems and homes, we have to take its word for it.

And while the vast majority of people who have frail and vulnerable elderly relatives in care are happy with the dedication and caring concern of staff, there is no doubt the system has real failures.

While a lot is promised, the sort of coordination and support needed, firstly, to keep old people within the community, and secondly, to ensure that when they are in nursing homes they get the best possible care, is often simply not available.

Is there any way for people to be reassured that the homes where their loved ones are being cared for are operating to best practice?

The first of the HSE's inspectorate reports have just been published on the HSE website, www. hse. ie, but as a guide to anybody looking for a nursing home, it is next to useless. Some entries are just a couple of paragraphs long and say the specific home is in broad compliance with health and safety legislation covering nursing homes . . . a fact that can give some indication that basic standards are being met.

Others point to defects such as faulty overhead bed lights or bedside alarm bells, or describe a urinal left in a plastic bin.

Another praises a home for its total refurbishment.

But they say nothing about the ethos, the care, the atmosphere, or the standard of nursing anybody can expect to receive in the home. Compliance does mean that private nursing homes won't get registration unless they can provide details of fees, fire safety, drug record maintenance, cleanliness and staffing levels and the sort of stimulation and entertainment that's available.

All homes are supposed to get two inspections a year . . . but again, this simply does not happen. In 2004, only 80 out of 450 homes were inspected, and then only once.

Is the inspectorate independent?

No, and this is a big problem recognised by Mary Harney, who is in the process of setting up an independent inspectorate. Again, this was supposed to happen two years ago, but the legislation has yet to surface.

The idea is that the new nursing home inspectors will be part of a wider independent inspectorate of social services, to be set up under a Health Information and Quality Authority. The minister says she'll publish the new bill in the autumn . . . it's due around now.

These sort of changes were promised back in 2001 as part of the last programme for government, but . . . as with all things in the health service . . . change comes very slowly. We are talking about nursing homes for the very frail and the very elderly. In that intervening period, many would, of course, have died waiting for a change.

So are poor conditions, care practices, a lack of staff training and poor hygiene widespread?

The problem is, we don't know. There are currently 20,000 people in public and private nursing home care in this country.

There is no doubt that the vast majority are well cared for by nursing and care staff whose patience and kindness is highly valued.

But the vast majority of old people are there because they are so frail of body and mind that their families can no longer look after them. They are incredibly vulnerable as a result. Many have no family and if they do, these relatives can't reasonably be expected to monitor everything that goes on in their nursing homes all day and all night.

This is why an independent, effective and accountable inspection regime, with the clout to punish those who breach standards, underpins public confidence in our entire nursing home system.