Doctors in the Republic of Ireland missed an early opportunity to terminate the pregnancy of Savita Halappanavar, a scathing report has found.
The Indian dentist later died from septic shock when she suffered a miscarriage in a Galway hospital.
The chairman of the clinical inquiry into the death of 31-year-old Savita Halappanavar revealed that he would have ended her pregnancy when she showed initial signs of the fatal infection.
But the renowned UK professor, Sir Sabaratnam Arulkumaran who headed the review on behalf of Ireland's Health Service Executive, refused to state when he would have acted or if it would have saved the dentist's life.
"It is very difficult. It's overall clinical judgment. I wasn't there to see how Savita was," he said.
The professor said that had Mrs Halappanavar had four-hourly pulse rate and temperature checks which recorded a rise, more tests could have been ordered and possibilities discussed.
"Unfortunately none of this was done so I can't really say when would have been the ideal time," he said.
The review team highlighted a litany of failings that made a significant contribution to the woman's death.
:: The interpretation of Ireland's strict abortions laws that only allows termination when there is a real and substantial risk to a woman's life.
:: Staff did not adequately assess and monitor Savita as an infection took over her body.
:: She was not offered all management options including termination.
:: Clinical guidelines relating to the prompt and effective management of sepsis at Galway University Hospital were also not followed, which includes removing the source of an infection.
Mrs Halappanavar's waters broke in the early hours of Monday morning and her condition deteriorated in the early hours of Wednesday morning.
Her widower Praveen, who is out of the country, has maintained that she repeatedly requested a termination but was refused because a foetal heartbeat was present.
Professor Arulkumaran said the consultant's plan to "await events" is appropriate when there is no risk to the mother or foetus, but stressed that monitoring, evaluation and clinical investigations would likely have led to reconsidering the need to expedite delivery.
By the Wednesday, a diagnosis of sepsis secondary to chorioamnionitis, an infection of the foetal membranes, was made which again would have merited expediting delivery to reduce the risk of infection to the mother, the review team said.
"The gravity of the situation was increasing but appears not to have been recognised and acted upon," the report found.
"Awaiting the blood results and not fully appreciating the deteriorating and complex clinical situation missed an opportunity for early and appropriate intervention with the help of multidisciplinary input."
It was almost another five hours before consultant Dr Katherine Astbury was called back on ward and a decision to terminate the pregnancy was taken, but Mrs Halappanavar later delivered her dead baby daughter.
Within hours she was in a high-dependency unit and intensive care where she died four days later from multi-organ failure from septic shock and E coli.
The report found that there was an over-emphasis on the need not to intervene until the foetal heartbeat stopped and not enough emphasis on the need to monitor and manage the risk of infection.
"The interpretation of the law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard," the report said.
The Irish Government moved to introduce legislation for limited abortion, as required by a 1992 ruling in the Dublin Supreme Court, on the back of a public outcry over Mrs Halappanavar's death.
Health Minister James Reilly said he has serious concerns about the revelations.
"It is a hard-hitting report which spares nobody and doesn't pull any punches," he said.
"It lays bare a set of unacceptable factors that led to the tragic death of a young woman."
The review team warned that similar incidents with a similar clinical context could happen again in the absence of clarity on the law and a lack of national clinical guidelines.
Prof Arulkumaran recommended that clinicians, health and social care regulators and politicians consider the law and guidelines on the management of inevitable miscarriage early in pregnancies and where there is a risk to the mother from infection.
The long-awaited report has been published two months after an inquest jury ruled unanimously that Mrs Halappanavar's death was by medical misadventure.
The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar's care before she died, but coroner Ciaran MacLoughlin said these failures did not contribute to her death.
Savita death outrage was catalyst for change
The death of Savita Halappanavar sparked international outrage over Ireland's strict abortion regime and a groundswell of support for reforms.
Ultimately it became a catalyst forcing the first Irish Government in 21 years to update laws to meet court rulings on a woman's right to a termination.
Within weeks, if enacted, the Protection of Life during Pregnancy Bill 2013 will legalise abortion in Ireland where there is a real and substantial risk to the life of the mother, including the threat of suicide.
It will legislate for the 1992 X case judgment from the Supreme Court in Dublin which found a 14-year-old rape victim who became pregnant had the right to travel for an abortion.
The Government was required to take account of a European Court of Human Rights ruling that a woman's rights were infringed when she was refused an abortion while in remission from cancer.
The proposed law states that one doctor is required to certify that a termination is justified in the case of medical emergencies. In such emergencies, the doctor involved will be required to certify his/her actions within 72 hours.
Two medics must agree and certify where there is a physical threat to the life of the mother and that termination of pregnancy is the only treatment that will save the mother's life. If possible, the woman's GP will also be consulted.
Anyone caught in breach of the legislation and intentionally destroying unborn human life will face up to 14 years in prison.
In a case of a real and substantial risk to a woman's life arising from suicide, the assessment process will involve three specialists, including one obstetrician/gynaecologist, and two psychiatrists, including one specialist with experience of dealing with the mental health of pregnant women, must jointly and unanimously agree and certify that the termination of pregnancy is the only treatment that will save the mother's life.
In such cases also, where feasible, the woman's GP will be consulted.
This issue caused intense debate among medics, campaigners and politicians as the legislation was being drafted, with psychiatrists split as to whether abortion should be offered to a suicidal woman or be classed as a treatment.
Committees reviewing decisions on whether an abortion should be allowed must make a decision in less than seven days.