The Ombudsman, Emily O'Reilly, has severely criticised Sligo General Hospital for the way that a man who died there five years ago was treated.
Ms O'Reilly was investigating a complaint made by the family of an unnamed man who died in the Sligo hospital in January 2000.
The man was admitted complaining of back pain and shortness of breath and died two days later of cardiac arrest.
Ms O'Reilly found that there was a delay in admitting him, a failure to communicate the seriousness of his illness to his family and a serious lapse in standards in relation to his dignity.
She also found information on the man's chest X-ray and oxygen doses was not recorded in medical notes.
She said that there was a failure to post a fluid restriction notice over the man's bed, necessary to maintain his safety, and a lapse of standards in relation to the administration of the last rites and in relation to dealing with the family after the death.
The family were unhappy with the treatment of their father before his death and complained of apathy from staff afterwards. They said that no one offered them condolences.
Their father's belongings, which they were asked to take home, had been left for collection in black sacks under a Christmas tree. When they examined the sacks later, one contained a box of disposable gloves.
She recommended that the Health Service Executive - North West Area - visit the family and apologise for the shortcomings at the hospital and make a €2,000 "time and trouble" payment to a charity named by the family.
She said that the HSE needed to develop protocols requiring staff at Sligo General to treat patients with dignity and respect, and bereaved people with compassion and understanding.
She also recommended that procedures at the hospital be reviewed to ensure that observations on a patient's condition are recorded in the medical and nursing records and are accurate.
"A point often made by complainants is that hospitals should learn from their past mistakes so as to ensure that other families do not experience similar problems," Ms O'Reilly said. "It is in this context that I have decided to publish this report."
A spokeswoman for the HSE (North Western Area) said that while they did not comment on individual cases, they had respect for the office of the Ombudsman and they would take full cognisance of her recommendations.
