The Special Dáil Committee on Covid-19 has recommended a public inquiry into cornavirus related death in nursing homes.
In its final report, the committee is sharply critical of delays in the State's response to the spread of Covid-19 in nursing homes.
The report notes how public health authorities "became overly focused on preparing acute hospitals for the ongoing pandemic in February and Marc" and that the State "failed to recognise the level of risk posed to those in nursing homes".
Committee members also highlight the State's "silo type approach...that did nothing to prevent the spread of the disease".
In recommending a public inquiry to investigate each of the almost 1,000 coronavirus related deaths in nursing homes; TDs claim there are "unanswered questions as to why some nursing homes were free of Covid-19 whereas others were severely impacted through the death of residents and sickness of staff".
The report says this lack of answers has "exacerbated the pain and suffering" of the relatives of those who died - and that the committee failed to get satisfactory answers despite devoting more time to the issue than to any other.
The committee recommends the public inquiry should examine the "large scale discharge of patients from acute hospitals to nursing homes at the beginning of March" as well as the response of the HSE, Department of Health, NPHET and Government to virus related difficulties in nursing homes.
The Chief Medical Officer Dr Tony Holohan has consistently defended NPHET's decision not to recommend visitor restrictions on 6 March - however the committee recommends a public inquiry should examine this decision further.
The Committee also proposes a review into the impact of privatisation of Ireland's nursing homes - with 80% of residential care now provided for by the private sector.
TDs also emphasise an over reliance "on institutional care for our vulnerable population; with the HSE continuing to 'place residents in nursing homes that have compliance issues - especially with infection control".
Aside from nursing homes, TDs note how 'meat processing plants emerged as a significant hotspot for Covid-19 infections' and that an Oireachtas inquiry should be established to examine the spread of coronavirus in plants.
The committee concluded "the same level of regulation and protection is not extended to workers and their conditions of employment" as is to the "highly regulated food safety and hygiene".
TDs also recommend a statutory sick pay scheme - saying the transmission of Covid-19 in nursing homes, meat plants and direct provision centres was facilitated by workers who "felt compelled to attend for duty due to the absence of income support if they reported sick to their employer".
These workers, the report notes, posed a "high risk of unwittingly transmitting the disease".
The committee highlights inadequacies in the testing and tracing system, saying "the HSE has a lot of work to do to get it right; turnaround times are too slow and the testing of close contacts of positive cases is not robust."
The turnaround time for testing and tracing should not be more than 24 hours, TDs conclude.
It also criticises the State's communication strategy around Covid-19 and said Oireachtas committees should review the Communications of their Departments to ensure "no ambiguity or room for confusion".
Meanwhile, TD say there should be greater transparency around the data used by NPHET to recommend restrictions- and the data should be peer reviewed by an Independent expert panel.
An urgent review is also needed before the end of 2020 for the regulatory framework of Health and Safety Authority and HIQA - with neither able to fully investigate compliance, the report concludes.
The Committee, which was established to examine pandemic response during the interregnum of the acting Fine Gael-led.