A coroner has criticised the amount of information entered in the medical charts of Savita Halappanavar after she died.
Dr Ciaran MacLoughlin said he has never seen so many retrospective notes added to a patient's file, some dated up to two weeks after her death.
"I would certainly be concerned about putting in retrospective notes two weeks after the event, memories fail," he warned.
The coroner questioned why different disciplines did not have separate notes, instead of clinical staff adding to nursing charts later making them "very difficult to follow".
He rejected claims by senior obstetrician Dr Katherine Astbury, who cared for Mrs Halappanavar, that they gave continuity.
"That didn't work," he said, looking at Mrs Halappanavar's chart.
"Nobody pointed out to you that the doctor at 6.30am had a very serious and very pertinent finding."
The coroner criticised the system when it emerged Dr Astbury's registrar, Dr Anne Helps, did not see another medic's entry that Mrs Halappanavar could have sepsis caused by chorioamnionitis, an infection of the foetal membrane identified through a discharge.
The obstetrician claims had she known, she would have started terminating the foetus then regardless of a heartbeat, instead of five hours later when she developed severe sepsis. Mrs Halappanavar died four days later.
Dr Astbury told the coroner none of her entries were post death but that consultants observations were added to charts as nurses were not always on ward rounds.