A report into the care of Savita Halappanavar who died after being refused an abortion in the Republic has found failures by staff led to her death.
Mrs Halappanavar (31) progressed from sepsis to septic shock before dying in University College Hospital Galway last October.
She was was 17 weeks' pregnant and told she was miscarrying when admitted to the hospital.
The final report from the Republic's Health and Safety Executive confirms findings and conclusions in an earlier draft showing the gravity of her condition was not grasped in time and Mrs Halappanavar was was not properly investigated or monitored.
Gerard O'Donnell, solicitor for Savita's husband Praveen, said his client does not believe the report explained why his wife died and he wrote to the HSE seeking a meeting with the chairman of the inquiry, the UK obstetrician Prof Sir Sabaratnam Arulkumaran. It is understood that the meeting will take place this week.
There was an over-emphasis on the need not to intervene while there was a foetal heartbeat, although Mrs Halappanavar was going to suffer an inevitable miscarriage, it was reported. The inquiry team found that Savita, who was admitted to hospital on October 2, was not diagnosed with probable sepsis until the Wednesday morning – but by lunch time she was found to have progressed to septic shock.
The report points to what appears to be a cautious approach by the medical team on the Wednesday when a possible termination was discussed.
The report notes the ruling of Judge Hugh O'Flaherty in the X case, which allows for abortion where there is a "real and substantial risk to the life of the mother".
A consultant caring for the expectant mother said: "If there is a threat to the mother's life you can terminate. If there is a potential major hazard to the mother's life the law was not clear..."
Mrs Halappanavar suffered a miscarriage at around 3.15pm on the Wednesday and was transferred to the high dependency unit before being placed in intensive care that night.
Her husband said both he and his wife had requested a termination on a number of occasions.
The HSE draft report contains a number of key points:
• Savita was 17 weeks' pregnant when admitted to hospital and told she will miscarry.
• Blood tests signalled suspected blood poisoning.
• Savita's husband stated they both asked several times for a termination.
• Savita's condition deteriorated and she suffered a cardiac arrest and died.