The report into how a man who should have been in prison was free when he attacked another man who subsequently died has found that more than 25 gardaí knew or should have known he was unlawfully at large.
Martin McDonagh attacked Noel Keegan, a retired member of the Defence Forces, and his wife Marie, on New Year's Eve.
Mr Keegan subsequently collapsed and died.
The report by the Inspector of Prisons is highly critical of the Courts, the Prison Service, the gardaí and the Probation Service and their failure to communicate with each other.
It found that neither the gardaí nor the Prison Service were informed that McDonagh should have been in jail because the Courts Service never sent the committal warrant, sentencing him to four years, to Castlerea Prison.
The Probation Service failed to supervise McDonagh in the community, even though it said it would when he was given Temporary Release in November 2009.
The report found that the PULSE computer system, used by the gardaí, cannot record the fact that a person is unlawfully at large and that the gardaí do not have access to the Prison Service's electronic prisoner log system.
This report says that a litany of flawed systems, outmoded work practices and the failure of organs of the justice family to communicate with each other, combined with lapses of judgement, misjudgements and inattention to detail ended in tragic consequences - namely the death of Mr Keegan.
McDonagh was serving a two-year sentence when, on 28 April 2009, he was sentenced to another four years.
However, he was not in court for that sentence and the Courts Service never sent the warrant to Castlerea Prison where McDonagh was in jail.
He was granted temporary release in November last year after the Probation Service said it could supervise him in the community.
However, it sent a letter to a wrong address and when he did not turn up in December for a meeting with a Probation Officer, the Probation Service did not report this to Castlerea or anyone else.
McDonagh was supposed to sign on at the prison and Longford Garda Station while on temporary release, but the prison service did not tell the gardaí this and even though McDonagh breached the terms of his temporary release, the gardaí did not know.
Ten days after he failed to sign on at the prison, Castlerea told Garda headquarters, but it failed to alert gardaí that McDonagh was at large through Forgra Tora, the Garda's internal bulletin.
It also cannot record the fact that McDonagh or anyone else was unlawfully at large and therefore gardaí accessing the PULSE system cannot know if a prisoner is free when he should be in jail.
Gardaí in Longford were told by Castlerea on 17 December that McDonagh was at large but he was not arrested - and 14 days later he attacked Mr Keegan.
The report says apprehension of person's unlawfully at large is not given the priority it warrants at senior management level.
The report makes a number of recommendations most of which have been implemented.
Fine Gael Justice Spokesman Alan Shatter said recommendations made by the inspector should be implemented to ensure such a tragedy never happens again.