The Leas Cross nursing home, the disability service provider St Michael's House and the former Northern Area Health Board must together bear responsibility for what happened a 60-year-old disabled man, an independent report into his death has found.
The report says Peter McKenna, who had Down syndrome and Alzheimer's disease, was "let down by the system".
He had been cared for by St Michael's House for 23 years and it decided in September 2000 to move him to Leas Cross against his family's wishes. It said it no longer could care for his needs.
The report criticises the handover of his care by St Michael's House to Leas Cross and said he was seen once by the home's medical officer during his stay there. This was on the day after his arrival and the medical officer noted it could be difficult to manage him, given his needs, in Leas Cross.
The report also said medical reports given to Leas Cross were "contradictory and somewhat confusing".
In Leas Cross Mr McKenna was placed alone in an upstairs bedroom which had a call bell he could not use. There was just one nurse at night time in the home looking after him and more than 30 other patients.
Mr McKenna, according to the report, was diagnosed with a urinary retention problem and was taken to the A&E unit of Beaumont Hospital on October 9th, 2000, and had a catheter inserted. He was sent to Leas Cross the next day.
He returned to Beaumont for an appointment on October 12th but missed a further appointment in relation to having the catheter removed on the 16th, the report said. However Leas Cross claims this was because no bed was available for him in Beaumont that day.
Mr McKenna had to be rushed to the hospital's A&E unit on October 22nd and he died later that day. Doctors there believed his condition had deteriorated over a number of days. He was dehydrated and his level of hygiene was poor. The cause of his death was blood poisoning.
"To a greater or lesser extent St Michael's House, Leas Cross nursing home and the Northern Area Health Board bear a responsibility for what happened to Peter," Mr Hynes concluded.
He said Mr McKenna's family were told by St Michael's House it would not provide clinical back-up if he went to another home. But the report questions the level of support it did provide once he went to Leas Cross.
It also notes that his social worker and psychologist were changed at the time of his transfer to Leas Cross which was "to say the least unhelpful".
Mr Hynes said there were "lessons to be learnt from this case". He concluded that Mr McKenna's death could not be dismissed simply as a systems failure and he recommended the Health Service Executive arrange for his family to meet St Michael's House staff so they could have any outstanding questions answered.
Dan Moore, a brother of the deceased, last night described Mr McKenna's death as shameful. "How our Peter could have been sent, on the application of St Michael's House, to a nursing home that had subsequently to be closed down beggars belief but it happened to our Peter. After 13 days there we, his family, received back his dehydrated, blood-poisoned, blackened body. We never received any explanation," Mr Moore said.