A year after the tragic death of mother-to-be Savita Halappanavar, several Irish hospitals still posed serious risks to the health of pregnant women, a wide-ranging health investigation report has revealed.

The report last week by the Health Information and Qualify Authority (HIQA) on the death of Halappanavar at University Hospital, Galway, in October 2012, also pointed to 13 “missed opportunities” in her care.

Had they been identified and acted upon they could have resulted in a different outcome for Halappanavar, the report said. HIQA was also critical of the care provided by staff at the hospital for Halappanavar, and in particular her consultant Dr. Katherine Astbury.

The report said, “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”

Halappanavar, 31, was 17 weeks pregnant with her first child when she was admitted to the hospital complaining of back pain. She died a week later from septicaemia following a miscarriage.

Her death caused a storm of controversy, reigniting the abortion debate, amid claims by her 34-year-old husband that doctors had said she could not have an abortion because Ireland was a Catholic country. A midwife later admitted at the inquest that she made that comment.

The HIQA report is the third investigation into Halappanavar’s death, following on a report by the Health Service Executive (HSE) and the inquest.

It has restated criticisms of the clinical management of Halappanavar made in the earlier HSE report and at the inquest. But the HIQA report cast its net more widely by identifying shortcomings in maternity care generally and calling for a national review of maternity services.

The report revealed that HIQA wrote to the HSE twice in recent months to express concern about issues which could pose serious risks to the health of pregnant women whose clinical situation was deteriorating.

HIQA wrote that 12 of the 19 maternity hospitals have no high-dependency beds for maternity patients and none has critical care beds. HIQA said it remained concerned that assurances given were not yet in place in all hospitals.

Minister for Health Dr. James Reilly has promised to ensure that the recommendations of all three reports are fully implemented.

Separately last weekend, the president of the Irish Hospital Consultants Association Dr. Denis Evoy said the death of Halappanavar was a great disaster, not only for her family, but also for the obstetrician who treated her.

“It’s a great tragedy… It’s a great disaster for the family but it’s also a great disaster for that poor obstetrician. Her grief pales into insignificance compared to that of the family but you say a prayer that it’s not you,” Evoy said.