The report on deaths at the Leas Cross nursing home in north Dublin - which found shocking deficits in the care provided to elderly residents - has now been passed on to the Garda Síochána.
Following its publication yesterday, it was sent to the Garda Commissioner by the Health Service Executive (HSE) and it has also been sent to the bodies responsible for policing the nursing and medical professions, An Bord Altranais and the Medical Council.
The HSE, which commissioned the report, said it regretted what happened at the private nursing home in Swords and was embarrassed by it.
The author of the report, consultant geriatrician Prof Des O'Neill, said in his review that his overall findings "are consistent with a finding of institutional abuse".
In one case he found nurses had difficulty contacting a doctor for a resident, which extended for three days. And having reviewed the case notes of 105 people who died at Leas Cross, or immediately after transfer to hospital from the home between 2002 and 2005, he said it would be a "very major error to presume that the deficits in care shown in Leas Cross represent an isolated incident".
Prof O'Neill found staffing levels at the home to be deficient. He also identified failures in the regulatory process, criticised those in management for not taking complaints seriously and said "there is scant evidence that the Department of Health has taken cognisance of the huge concerns internationally over the quality of care provided to older people in long-term care".
"With a few honourable exceptions there has been a systematic failure by Government, health boards and professional bodies to address the issue of appropriate quality of care for older people with the highest levels of health and social needs in Irish society," his report added.
Aidan Browne, director of Primary, Community and Continuing Care with the HSE, said all recommendations in the report would be taken on board.
Asked what actions would be taken against staff to ensure they were held accountable, he said: "If you read the report and you read the submissions, there is no evidence that people actually did anything wrong. The evidence is that the combination of factors came together that resulted in a wrong outcome."
He said improvements had now been made to the HSE's nursing inspection process.
Submissions made by people referred to in the report, but not named in it, were published with the report. In its submission the Department of Health said that some criticisms of it by Prof O'Neill were made out of context and were not backed up by any evidence. And a former senior health service executive described parts of the report as "biased and inaccurate".
Minister for Health Mary Harney described the report's findings as "deeply upsetting" and promised legislation to allow for the setting up of an independent inspection regime for all nursing homes. She said she wanted to see the legislation through the Oireachtas "hopefully before Easter of next year".
Meanwhile Mr Browne revealed there are still some nursing homes with problems but the HSE was "working very diligently" with them to improve them.
Families of some of those who died at Leas Cross confronted HSE officials at a press briefing on the report yesterday saying attempts had been made to block their entry. They said they were "treated like lepers" and demanded that somebody be held accountable.
Leas Cross first came to prominence in March 2005 when the Dublin city coroner heard an inquest into the death of 73-year-old woman who died at Beaumont Hospital shortly after being transferred to it from the home. Her daughter told the inquest her mother, Dorothy Black, had bed sores the size of melons which penetrated into the bone when she was admitted to Beaumont.
Shortly afterwards Prime Time Investigates sent an undercover reporter into the home and its programme finally led to Leas Cross closing in August 2005.
Last night the owner of Leas Cross, John Aherne, told The Irish Times he should have been informed of any failings in care standards at the home, but that the HSE did not raise any concerns with him. "I am the owner of the nursing home. I have no medical background myself. If anything was wrong, the inspection team should have informed me we received certainly no more than four reports over seven years."