The Irish Patients' Association (IPA) has said the inquest into the death of baby Luke Kelly has exposed not just individual shortcomings in the health service but "a deeper systemic failure".
It comes after a verdict of medical misadventure was returned by the coroner for Co Cavan, Dr Mary Flanagan, after hearing two days of evidence this week.
The IPA has said the courage of Luke's parents, Barry Kelly and Helena Lyons from Shantemon, Co Cavan, "in speaking publicly, even in the face of profound loss, must now become the catalyst for change".
The Irish Patients' Association said the absence of a formal afternoon handover in a paediatric unit caring for medically complex children contravenes HSE clinical guidelines.
It also said that HIQA's National Standards for Safer Better Healthcare demand safe transitions of care and effective communication at every point and they said these are not optional extras; they are basic safeguards. The inquest heard that Luke went 18 hours without a physical examination by a consultant at the hospital despite his condition deteriorating.
The coroner was also told that the Cavan General Hospital had no formal afternoon handover process in place at the time. The hospital offered an apology to Luke's mother and his father during the two day inquest that was held at Cavan Courthouse.
