The State's response to Covid-19 at the start of the pandemic failed to recognise the threat posed by the virus to nursing home residents.
The Dáil's Special Committee on Covid-19 Response found that a "silo-type" approach in relation to nursing homes "did nothing to prevent the spread of the disease".
The damning findings are included in the comm- ittee's final report, which recommends a public inquiry be set up to investigate each of the almost 1,000 deaths recorded in nursing homes.
In his commentary, committee chairman, Clare Independent TD Michael McNamara, said there are "more answers needed" on deaths in nursing homes.
Mr McNamara said that unless the State learns from all of the analysis on the pandemic, "the many sacrifices will have been in vain, as will the too-many heart-breaking deaths".
The committee's main recommendation is for a public inquiry into deaths in nursing homes.Satisfactory
The report says that despite devoting more time to the issue of nursing homes than to any other setting, the committee was "unable to get satisfactory answers as to why 985 residents of nursing homes died after they contracted Covid-19".
The committee examined reports by the Health Information and Quality Authority (Hiqa) and an expert panel on nursing homes.
It says these reports "highlight a silo-type approach on behalf of the State that certainly did nothing to prevent the spread of the disease."
Among key issues identified are an over-focus on preparing acute hospitals for the pandemic and a failure to recognise the level of risk posed to those in nursing homes.
The committee recommends a public inquiry that will investigate and report on all circumstances of each individual death from Covid-19 in nursing homes.
The report says the actions taken by the Government and public health authorities "cannot be examined in the light of what we now know about Covid-19, its transmission and treatment, but instead must be examined in the light of what was known, or ought to have been known, at the time when such measures were taken".
On Covid-19 testing, the committee recommends the State develop a system that has a turnaround time that does not exceed 24 hours.
The committee found meat processing plants were a significant corona- virus hot spot.
The report says that while meat processing is highly regulated regarding food safety and hygiene, "the same level of regulation and protection is not extended to workers and their conditions of employment".
The committee recommends an Oireachtas "Inquire, Record and Report Inquiry" into the operation of the industry.