1. It is clear that Leas Cross was not in a position to fully care for Peter McKenna.
2. When assessing the suitability of a nursing home for patients, its registration should be taken as a basic requirement but not as the sole consideration.
3. Other factors including a patient's needs and the home's ability to cater for these must also be taken into consideration.
4. A full written report should be provided to any unit to which a patient is being handed over.
5. The Health Service Executive should advocate on behalf of the family of Peter McKenna to ensure they have all their outstanding questions answered.
6. There should be available within the HSE an integrated system for complaints so that complaints coming from a number of sources can be linked and dealt with effectively.
7. The nursing homes inspection process should be reviewed.
8. The size of nursing homes should be restricted to perhaps 50 beds.
