A new report says proper patient assessments would have made staff in a mental health facility more aware of their suicide risk.
It follows a review by the Inspector of the Mental Health Services in the Carlow/Kilkenny and South Tipperary area.
The Chairman of the Mental Health Commission John Saunders admits the possibility that lives could have been saved can't be proven, but staff could have been more aware of risks if assessments were more consistent.
13 patients died by apparent suicide in a two year period.
Mr Saunders says the Commission also has concerns about where patients are cared for:
