A damning report into the death of Indian dentist Savita Halappanavar, who died after being refused a termination as she miscarried, has concluded medics failed to give her the most basic care.
Halappanavar was 17 weeks pregnant when admitted to University Hospital Galway on October 21 last year. She died a week later after suffering a septic blood infection, after she was refused a termination.
The watchdog Health Information and Quality Authority (Hiqa) said doctors failed to recognize the 31-year-old was suffering from an infection and failed to act on signs that her condition was deteriorating.
This was the third inquiry into Mrs Halappanavar's death from sepsis.
Director of regulation Phelim Quinn said there was a series of missed opportunities in her care.
"The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar," he said.
"Effective care and treatment depends on the regular monitoring and recording of a patient's clinical observations and recognising their significance, acting appropriately on the findings, escalating concerns and the seamless clinical handover of information relating to each patient within and between clinicians and clinical teams."
Key findings of the 257-page Hiqa report included:
*General lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in Mrs Halappanavar's case.
*Failure to recognise that Mrs Halappanavar was at risk of clinical deterioration.
*Failure to act or escalate concerns to an appropriately qualified clinician when Mrs Halappanavar was showing signs of clinical deterioration.
Last April an inquest into her death in returned a verdict of death by medical misadventure.
Her widower Praveen Halappanavar is suing Galway University Hospital and his wife’s consultant Dr Katherine Astbury.