An investigation into the failure to dispatch an ambulance to an incident in Cork last May following a 999 call has said deviations from procedures and priority dispatch standards resulted in a decision not to send the ambulance.
Two-year-old Vakaris Martinaitis died from injuries he sustained in a fall from an upstairs window at his home in Midleton.
He was brought to hospital in a neighbour's car under garda escort.
An inquest into his death earlier this month returned a verdict of accidental death.
The inquest heard that an ambulance due to be dispatched was "stood down" because the controller dealing with the 999 call believed the child had suffered a simple fall at his home.
The Health Service Executive set up an investigation into the incident and the investigation team's report was published this morning.
The 54-page report makes 11 recommendations.
It says two main reasons were identified for standing down the ambulance following the 999 call.
The report says there was a deviation from procedure, which failed to appropriately assess the child's condition and to provide post-dispatch advice to the caller.
It also says there was a deviation from priority dispatch standards, which resulted in a decision not to send an ambulance.
It says this decision was not based on correct or complete information.
The report recommends that a higher level of priority must be given to a call where limited information is available or where a person involved does not speak English.
The National Ambulance Service, which asked for the external review, said all of the recommendations will be implemented in full.
'Lessons learned' from tragedy
Speaking on RTÉ's News at One, Medical Director of the National Ambulance Service Dr Cathal O'Donnell said lessons have been learned from the tragedy and the report would be accepted in its entirety.
Dr O'Donnell said the failure of two staff members to adhere to agreed procedures led to an ambulance not being sent.
"The call was not handled in the control centre in Cork as it should have been," he said.
Dr O'Donnell said there was a degree of confusion from the caller (an Irish person) and language difficulties at the scene.
However, he added: "Irrespective of the nature of the call, an emergency ambulance should be dispatched on every occasion for every 999 call, and on this occasion that did not happen."
Dr O'Donnell confirmed an internal investigation into the actions of the two staff members is under way.
Asked if the delay in getting Vakaris to hospital contributed in any way to his death, Dr O'Donnell said it was his opinion that it would not have affected the ultimate outcome.
He said the National Ambulance Service had apologised to the family.
The independent review was established following public concern over emergency cover in the east Cork area.
However, the independent chair of the investigation, Dr David McManus, said it is important that the public be reassured that resources were not the problem.