Relatives of former residents of Leas Cross have said the O'Neill report, which found 'systematic abuse' at the nursing home, still leaves many questions unanswered.
The report, which found care was deficient at many levels and consistent with a finding of institutional abuse, has been sent to the Garda Commissioner, the Nursing Board and the Medical Council for their consideration.
The review of deaths at the Leas Cross Nursing Home between 2002-2005 was carried out by by consultant geriatrician, Professor Des O'Neill.
Prof O'Neill concluded that management and the clinical leadership did not recognise the care required to meet the needs of the residents.
The report also included criticism of the former Northern Area Health Board, the HSE, and the Government, which it said failed to provide policy and legislation over a number of years to address the complex needs of the elderly.
Prof O'Neill questioned the regulatory process operated by the then Northern Area Health Board. He said there was an almost complete absence of systematic monitoring of deaths in nursing homes.
The HSE has said that its new inspection regime is consistent, robust and vastly improved.
The report concluded it would be a major error to presume the deficits identified in Leas Cross represent an isolated incident.
It also called for urgent updating of nursing home legislation.
After the Leas Cross nursing home closed in August of last year, the HSE commissioned Prof O'Neill to review care and deaths there between 2002 and 2005.
His report was submitted to the executive last May but was not published because the executive said those criticised in it had to be given the right of reply. Those replies are appended to the O'Neill Report.
Former CEO regrets incidents
Following the publication of the report, the former chief executive of the NAHB said she deeply regretted that a number of patients at Leas Cross were injured during their residency.
She said that the health board was unable to have sufficiently robust oversight systems in place that might have identified the problems.
The owners of the Leas Cross nursing home submitted that, in relation to patients who died there or at a local hospital, there was no evidence of contributory negligence to those deaths.
Meanwhile, the Department of Health and Children has rejected claims in the report that departmental policy regulations have failed in the sector for many years.
It said national standards of care in relation to nursing homes have been in place since 1993. But speaking today, Minister for Health Mary Harney said agencies were playing 'catch-up' in terms of care of the elderly.