It criticised the decision-making at the hospital, the workload placed on midwives and the lack of guidelines for dealing with critical cases.
On March 9, 2007 Ms McCabe, 34, gave birth to twins seven months into her pregnancy.
She had arrived at the hospital two days earlier when her waters broke but was discharged. After being readmitted and having a caesarean section, she and one of her sons died.
The review confirmed Ms McCabe was discharged from hospital hours after her waters broke due to misdiagnosis and an over-reliance on chemical tests.
Ms McCabe became critically ill shortly after being readmitted but early warning signs of septic shock were not recognised.
The review also revealed Ms McCabe’s son Zach had an undetected defect which meant he would not have survived outside the womb.
The review said his death was unrelated to the hospital’s treatment of his mother and his abnormalities are recognised as being difficult to diagnose before birth.
The report was produced by a four-person team chaired by Dr Seosamh Ó Soigligh, a consultant obstetrician. On the strength of its findings, the team made 27 recommendations, 15 of these were labelled as “high-priority”, including:
An urgent increase in midwifery and medical staff.
The HSE must streamline its operation to ensure there are safe staffing levels in areas of emergency care.
The workload on staff at Our Lady of Lourdes be reassessed to allow realistic time for consultants to fulfil administrative duties.
An awareness-raising campaign to educate nurses about the early warning signs for septic shock.
Midwives should be directly involved in ward rounds to ensure they are aware of all patient details.
In a personal note, the team thanked Ms McCabe’s husband, Aidan, and her mother, Barbara Corcoran. It said their attitude was “humbling”.
“This incident was a catastrophic and tragic event. In the space of a few hours Tania’s husband Aidan lost his wife and son during what should have been a time of joy,” it said.
Earlier this week, Mr McCabe’s father, Philip, said after reading the report the family still had questions.
For its part, the HSE issued a statement last night outlining the improvements it said have been made in Our Lady of Lourdes and the wider health system.
It said it had got approval for 22 extra midwife posts and all bar six of these have been filled. Three additional obstetricians have been hired following a report into disgraced consultant Michael Neary.
The HSE said it is committed to addressing all outstanding issues raised in the report into the deaths of Ms McCabe and her son.