The official report in to the death of Patrick Joseph Walsh in Monaghan Hospital has heavily criticised consultants there and at Our Lady of Lourdes and Cavan hospitals.
It says that while Mr Walsh's death may have inevitable, it was avoidable in the circumstances in which it occurred.
The report finds that the failure of the on-call consultant on Monaghan Hospital to personally phone consultants in Our Lady of Loudes Hospital and Cavan General Hospital “fell well short of good clinical practice.”
It also criticises consultants in Our Lady of Lourdes and Cavan General Hospitals for not immediately accepting Mr Walsh when requested to do so.
It says all of those involved in the incident were guilty of allowing interpersonal disputes make them lose track of patient care.
The report recommends that acute in-patient services at Monaghan Hospital be suspended as soon as possible.