The Health Service Executive has published the report into the circumstances surrounding the death of a 34-year-old woman who died after giving birth to twins, one of whom also died, at Our Lady of Lourdes Hospital in Drogheda.
It said today steps have now been taken to implement recommendations and address weaknesses in the hospital's systems following Ms McCabe's death in March last year.
The report, which was seen by The Irish Timesearlier this week, found that doctors at the hospital failed to diagnose that Tania McCabe's waters had broken.
Ms McCabe presented at the hospital on March 6th, 2007, believing her waters were breaking. However, her consultant believed she had "an episode of urinary incontinence rather than a rupture of membranes", the report found.
She was kept in overnight and the following morning, a midwife noted she believed the woman's waters had broken. This information does not seem to have found its way to the consultant who decided to discharge her and review her condition on March 9th, by which time she was dead.
The report, officially published today, again draws attention to staffing deficits at the Drogheda hospital.
The investigation team found maternity, paediatric and anaesthetic services are "significantly under-resourced to cope with the current demands" and that this had an impact on Ms McCabe's care.
Ultimately, it said, the care provided to Tania was "compromised by [the staff's] workload and the environment in which they were working".
The HSE said today its representatives had met with the family of the late Ms McCabe again this week and they had again expressed their sorrow for the loss the family has experienced.
"The HSE also acknowledges the huge trauma that staff at the hospital have undergone," a statement said.
"Recommendations to deal comprehensively with the weaknesses identified are made and prioritised in the report. There are a total of 27 recommendations, of which 15 are high priority, eight are medium priority and four are low priority."
The HSE said it is committed to addressing the recommendations set out in the review and progress has already been made in their implementation.
"The Department of Women and Children's Health within Our Lady of Lourdes has embraced significant change over the last number of years - the number of consultants Obstetricians has increased from four posts to seven posts, there are six consultant paediatricians.
"Three additional consultant anaesthetists were appointed in 2007. A consultant haematologist was appointed to the hospital in 2006. 22 additional midwives were approved. This has raised the approved staffing complement from 66.8 whole-time-equivalent midwives to 88.6 whole-time-equivalent midwives, with an additional 10 midwives in the midwife-led unit."
"Significant investment in recruitment has resulted in all but six of these posts being filled. This brings the midwife to patient ratio to 1:48. There are currently six midwives vacancies in the maternity department in Our Lady of Lourdes Hospital, Drogheda and efforts are currently being employed to address this."