A report into the death of baby Mark Molloy at Portlaoise Hospital in January 2012 has found two main care delivery issues in his death.
The HSE said the staff failed to recognise and act on the signs of foetal distress.
The report is published today at the request of the Molloy family, and it makes 43 separate recommendations.
The HSE has again apologised to Mark and Roisin Molloy for the events that occurred on January 24, 2012, related to Rosin's labour and delivery and for the death of baby Mark.
Mark Molloy has said although himself and Roisin received the report two years ago, the HSE did not intend to publish it.
He said: "The HSE were never going to publish this report. I mean in the immediate aftermath of the report being completed, myself and Roisin met the HSE to discuss how they were going to implement the 43 recommendations in the report.
"They had never an intention to publish this report until we put the push on Tony O'Brien two weeks ago."