A jury today said the failure of health services to change their procedures following the drowning of a mother and her two young children was an absolute disgrace.
Sharon Grace (28) from Barntown, Co Wexford, called to the reception of Ely Hospital just outside Wexford town seeking a social worker around 7.30pm on Saturday evening, April 16th, 2005.
She left with her two young daughters - Mikhala (4) and Abby (3) - after being told they had no emergency contact numbers for social services.
Hours later, around 10am on Sunday four fishermen discovered their bodies floating alongside each other at the Kaat's Strand area of the River Slaney in Co Wexford.
Jury foreman Sean Meyler said: "I know there are times when mere words cannot help the situation, but the fact there was no change in procedure from that time to this day means that this could happen again.
"That is the greatest insult to the memory of that woman and those innocent children. Surely something must be done or could have been done?
"It might be simplistic, but in a country awash with money that three lives, a woman and two innocent children, should be lost is a disgrace."
A receptionist at the hospital, Marian Redmond, who spoke with Mrs Grace hours before her death, told the inquest there was still no list of emergency numbers for social services at the reception of Ely Hospital.
South east Wexford Coroner Jimmy Murphy said it was incredible Mrs Grace's cry for help at Ely Hospital had failed and nothing had been done to alter procedures a year and six months later.
Mrs Grace's father, Eddie Reddy, said: "It is an absolute scandal that is what it is, social services should be ashamed of themselves 10 times over." He said they should be ashamed nothing is being done at a time when suicide is claiming more lives than road crashes.
At the inquest in the Whitford House Hotel in Wexford, the jury concurred with State Pathologist Marie Cassidy's evidence of death by drowning.