The bug was a definite "contributory factor" in the demise of these people although the main causes of death were other underlying illnesses, a damning report revealed yesterday.

The report which investigated the outbreak showed 46 patients were struck by the potentially lethal infection while being treated in the hospital in the first six months of last year -- 21 of these are now dead.

It exposed a catalogue of weaknesses which put patients at risk:

> A virulent strain of the infection was circulating in the hospital at a time when it was so overcrowded its occupancy levels were at "105pc".

> Its infection prevention and control committee -- which should have been monitoring the threat of these bugs -- "was in abeyance" for months.

> Although scrupulous cleaning is needed because patients with C difficile suffer diarrhoea which can spread the highly contagious infection, its bed pan washer was leaking and suffering breakdowns -- leaving staff to wash them by hand.

> The hospital had no microbiologist and depended on telephone advice on infection control from specialists in Limerick.

> The Director of Nursing was away on special assignment from March to October.

> Guidelines to reduce infection produced by concerned nurses were only followed in a patchy manner. There were practical difficulties isolating infected patients and poor attendance at staff training.

The report by senior HSE executive Dr Kevin Kelleher and Dr Mary Hynes showed the hospital had "no effective surveillance system for C difficile" at the time when 50 outbreaks were recorded.

"While there was some awareness of an increased level of C difficile in the hospital in the first three months of 2007, particularly by infection control nurses and medical consultants, the extent of the problem was not appreciated initially by either management or clinical staff in the hospital, many of whom considered MRSA or norovius a bigger threat".

Dr Kelleher told the Irish Independent last night the increase in infections was picked up as a result of a regular analysis of healthcare associated infections in the mid-west region -- a surveillance system which is not in place in other areas around the country.

It found that of the 46 patients infected, 15 died within 30 days of diagnosis. Thirteen of those who died were 75 years or over and two were 65-74 years old.

The report said according to death certs none of the 15 died directly from C difficile. It was mentioned in the death certs of eight patients and recorded as contributory cause in nine of their medical notes.

Since the outbreak measures have been put in place and the number of cases has fallen.