The hospital in the Republic where a woman who was refused an abortion died almost a year ago failed to give her even the most basic elements of care, a new damning investigation has found.
Savita Halappanavar was the victim of several "missed opportunities " to potentially change the outcome of her care at University Hospital Galway.
The latest verdict on the tragedy is contained in an investigation by the Health Information and Quality Authority (HIQA), which spent months probing the circumstances behind the tragedy.
Ms Halappanavar (31) was 17 weeks pregnant when she was admitted to the hospital and told she would miscarry. Both she and her husband Praveen asked for a termination but were refused because the foetus had a heartbeat.
However, she had a potentially virulent infection which was missed by staff who, an earlier HSE-commissioned report said, failed to properly assess and monitor her. This sepsis progressed to septic shock and she died a week later.
The HIQA report said that following the rupture of her membranes she should have received four-hourly observations, including checks on her temperature, heart rate, breathing and blood pressure.
But this did not happen and the staff failed to act in a timely way to respond to her deterioration. By the time she was admitted to the critical care unit it was too late.
Key findings revealed:
e The hospital did not follow its own guidelines on early warning alerts for a patient who could be deteriorating.
e It also ignored its guidelines on sepsis and pre-term pre-labour rupture of the membranes.
e Vital information about her condition was not shared by doctors looking after her.
e She was placed in St Monica's ward where there was a mix of patients and unsuitable to care for someone at risk of clinical deterioration. There were not enough staff qualified to treat a diverse patient mix.
e The arrangements in place for clinical governance by which healthcare teams should share responsibility and accountability for quality of care were "unnecessarily complicated".
Last night, the hospital apologised to Praveen Halappanavar. It said the hospital group was determined to ensure the safety and welfare of all patients attending UHG and the other six hospitals in the newly established group.
"A special board meeting next week will consider all of the findings and recommendations and identify what further action needs to be taken," a statement said.