Blame for Bessborough infant deaths lays with State

At that period most births were at home, and not in hospitals under supervision of expert doctors. Bessborough was not a hospital. It replicated a home environment with some qualified nurses. Expert medical oversight was the responsibility of the local State Medical Officer.
Routine inspections of Bessborough and similar homes found them generally superficially clean, well-run by dedicated staff and with good care – but dealing with incoming patients frequently sick, undernourished and infected. The high mortality arose from the invisible bacteria which had become endemic in Bessborough and which state inspectors inexplicable failed to act on.