The Irish Health Service Executive (HSE) Clinical Review into the death of Savita Halappanavar has written that there was 'a lack of recognition of the gravity of the situation and the increasing risk to the life of the mother.'
According to RTE the review concluded this was either due to the way the abortion law was interpreted by medical staff dealing with the case, or by their lack of appreciation of the increasing risk to the mother.
Halappanavar died at Galway University Hospital on 28 October last year. The newly released investigation into her death has found a lack of recognition of the increasing risk to her life; it also found significant delays in aggressive treatment and it found failure to adhere to sepsis management guidelines.
Inadequate assessment and monitoring that would have allowed the clinical team to recognize and respond to the signs that the patient's condition was deteriorating due to infection was also revealed in the review.
Staff also reportedly failed to adhere to guidelines 'for the prompt and effective management of sepsis, severe sepsis and septic shock when it was suspected or diagnosed.'
The review found that when Halappanavar and her husband Praveen inquired about the possibility of having a termination it was not offered or even considered possible by the clinical team until the afternoon of 24 October, due to their assessment of the legal context in which it would occur.
Instead, from the time of her admission until the morning of 24 October, the plan for the patient was to 'await events' and to monitor the fetal heartbeat in case an accelerated delivery might be possible, once the fetal heart stopped.
Awaiting events can be clinically appropriate, provided it is not a risk to the mother or the fetus.
But the review concluded that proper monitoring and evaluation of Halappanavar's changing condition should have lead to a reconsideration of the need to expedite delivery.
The HSE report says that when the Halappanavar's requested a medically induced termination 8.20 A.M. on Tuesday, 23 October the consultant obstetrician advised them of Irish law.
The couple had asked about the possibility of using medication to induce miscarriage, as they said they did not want a protracted waiting time, when the outcome of miscarriage was inevitable.
But during her interview with the HSE Clinical Review team, the consultant on duty stated: 'Under Irish law, if there is no evidence of risk to life of the mother, our hands are tied so long as there's a fetal heart.'
'We can't predict who is going to get an infection", she added.
The report states that the staff who cared for Halappanavar were deeply saddened by her tragic and untimely death.
The report has called for efficient assessment and monitoring of the patient by the clinical team to enable them to promptly recognize and respond to the signs of infection and clinical deterioration.
The report also says that hospital guidance assumes that there would be four-hour monitoring of patient observations for patients with premature rupture of membranes. In Halappanavar's case the monitoring was less frequent.