An obstetrician treating an Indian woman who died in an Irish hospital after she miscarried should have got a second opinion to terminate the pregnancy sooner, an inquest heard.
An expert witness said Savita Halappanavar was also put on the wrong type of antibiotics for several hours for the strain of E coli she contracted.
Susan Knowles, consultant microbiologist at the National Maternity Hospital in Dublin, said there were "subtle" indicators the patient was showing signs of sepsis late on Tuesday October 23 last year and during the early hours of the following morning when she was found shivering in her bed.
Consultant obstetrician Katherine Astbury examined her patient at 8.30am and suspected sepsis caused by chorioamnionitis, an infection of the foetal membrane, but ordered tests.
"The decision making regarding induction of labour or to await spontaneous events once chorioamnionitis was clinically apparent is a critical part of the management of this case," Dr Knowles said in conclusions in a statement to the inquest.
"There is no mention in the note written after the ward round of a plan regarding delivery. One may infer that that decision was to await."
Dr Astbury has said she decided to carry out a termination five hours after her morning rounds as Mrs Halappanavar's condition deteriorated and she got a second opinion.
But Mrs Halappanavar naturally delivered a dead foetus at 3.30pm.
Dr Knowles said it was unclear when blood test results became available and said medical staff should have been called earlier when the patient's blood pressure continued to fall mid morning.
Mrs Halappanavar delivered a dead foetus on the Wednesday afternoon and died in intensive care of multi-organ failure four days later. Her widower Praveen is not at the hearing as has found the last few days so stressful.