An Indian dentist who was refused a termination in an Irish hospital as she miscarried died as a result of medical misadventure, a jury at her inquest has today unanimously ruled.
Savita Halappanavar was 17 weeks pregnant when admitted to University Hospital Galway on October 21 last year with an inevitable miscarriage.
She died a week later after suffering a septic blood infection.
A jury at her inquest in Galway courthouse also accepted nine recommendations put forward by coroner Dr Ciaran MacLoughlin.
The medical misadventure ruling found that there were systemic failures or deficiencies in the care given to Mrs Halappanavar before she died.
Widower Praveen Halappanavar should have been celebrating his fifth wedding anniversary with his wife today.
He was given a health service internal review of his wife's death on March 30, the day their baby Prasa had been due.
The jury deliberated for about three hours.
The recommendations are:
:: The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;
:: Blood samples are properly followed up;
:: Protocol in the management of sepsis and guidelines introduced for all medical personal;
:: Proper communication between staff with dedicated handover set aside on change of shift;
:: Protocol for dealing with sepsis to be written by microbiology departments;
:: Modified early warning score charts to be adopted by all staff;
:: Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;
:: Medical notes and nursing notes to be kept separately;
:: No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.
Dr MacLoughlin warned that the deficiencies or failures in the care of Mrs Halappanavar did not cause her death.
Mr Halappanavar sat with his legal team as the coroner, gardai, the jury and legal teams for the hospital and its staff sympathised with him.
The 34-year-old shook hands with the coroner and jury members at the end of the hearing, moments after his solicitor thanked the coroner for "extraordinary sensitivity and logic" during the inquest.
During seven days of often graphic and upsetting evidence, the jury heard that Mrs Halappanavar would probably still be alive today if the law in Ireland allowed an abortion as she miscarried before there was a real risk to her life, by which time it was too late to save her.
Leading obstetrician Peter Boylan outlined a number of deficiencies in her care, but stressed that none on its own was likely to have resulted in Mrs Halappanavar's death.
After the jury returned their verdict, Mr MacLoughlin spoke to Mr Halappanavar.
"Praveen I want to offer you my sincerest and deepest condolences on the death of Savita," he said.
"You showed tremendous loyalty in the love to her during her last week .
"The whole of Ireland has followed your story and I want, on their behalf, to offer our deepest sympathy.
"You will also be watched over and protected by the shadow of Savita who was in our thoughts during this painful and difficult journey."