One of the country's largest hospitals has been criticised for being grossly understaffed after a backlog of almost 58,000 X-rays was uncovered.
An inquiry into the scandal found a shortage of radiologists at Adelaide and Meath Hospital in Tallaght, whose workload was too high, while some 3,500 GP referral letters had been opened but not processed.
The Hayes Report revealed that, despite radiologists raising concerns 30 times between 2005 and 2009, there was an absence of formal policies and protocols at the facility, difficulties with radiology IT systems and persistent problems with the typing of reports.
The Health Service Executive (HSE) review was launched last March when Tallaght Hospital confirmed one patient had died as a result of the backlog, while another was undergoing cancer treatment.
The inquiry team, led by Dr Maurice Hayes, revealed severe systemic and other weaknesses at management level, while the structures of the hospital's board were not robust enough to provide governance, supervision and direction.
The HSE said it accepted the findings of the report and was implementing its recommendations.