Savita case turns spotlight on Republic's abortion law
Let down by the state, let down by the law, or simply let down by the doctors and midwives charged with Savita Halappanavar's care.
It is hard to imagine which of these scarred grieving widower Praveen the most after several harrowing days listening to clinical evidence which laid bare the final hours of his wife's life.
Six months on from the death, details emerged of a litany of system failures in the hospital.
Gaping holes were exposed in Ireland's abortion laws as well as shortcomings in her care, confusion over medical notes and deficiencies in staff communication.
As a devastated Ms Halappanavar miscarried, she looked to the future and spoke of her longing to be pregnant again by Easter, the weekend the baby daughter she had named Prasa was due.
Instead, on that day, March 30, her husband was handed a draft report of the internal review into her death.
The case again turned the spotlight on the Republic's controversial ban on abortion, its inadequacies flagged up by the country's leading specialist in obstetrics.
Peter Boylan, former master of the National Maternity Hospital, identified the "real problem" in her care - by the time there was a real and substantial risk to Ms Halappanavar's life it was too late.
Mr Halappanavar's insistence that his Hindu wife's pleas for an abortion were refused because "Ireland is a Catholic country" - a headline that beamed around the world - was held up in part.
Visibly shaken, midwife Ann Maria Burke admitted the remark.
"I was trying to be sensitive," she said, claiming she had been trying to explain the difference between Irish and Indian law.
Ms Halappanavar's consultant, obstetrician Katherine Astbury, was calm and authoritative in the witness box and insisted she never mentioned religion.
The doctor said she could not have terminated on the Monday or Tuesday, when Ms Halappanavar was well and her baby's heart beating. That decision has been backed by colleagues and superiors.
But questions remain over why the signs of her fatal infection were not detected in the early hours of the next morning.
By Wednesday it was, in Dr Boylan's words, "too late".
Ms Halappanavar was admitted to University Hospital Galway on Sunday October 21 suffering back pain and an "inevitable" miscarriage was diagnosed.
Notes showed that within hours there were deficiencies in her care, described by coroner Ciaran MacLoughlin as "system failures".
First the blood tests. On admission Ms Halappanavar had an elevated white cell count of 16.9 - a sign of infection. This was not noted on her chart and not investigated by medics who should have repeated the test.
Second, hospital guidelines were broken when her vital signs were not checked every four hours after her waters broke in the early hours of Monday. Those specific checks are designed to spot early signs of infection.
Thirdly, Dr Ikechukwu Uzochkwu disputes claims by midwife Ms Burke that he was told on Tuesday night of high pulse rates, again another sign of infection.
All specialists agreed on the fourth point - Ms Halappanavar was suffering from early stage sepsis when she was found shivering and her teeth chattering at 4.15am on Wednesday. Instead of a doctor being called she was given a blanket and paracetamol.
About 12 hours later severe sepsis had set in and Ms Halappanavar naturally delivered a dead foetus.
The tell-tale signs of the infection had been missed. The result was fatal.
Nurses and doctors have argued over who said what, when and to whom, and who did or did not read "significant" records on her charts.
Other evidence showed that the wrong antibiotics were initially prescribed to fight severe sepsis or a rare strain of the E.coli bug.
A blood sample to test for lactate - a key indicator of sepsis - was wrongly sent to the lab on Wednesday and returned to the ward unchecked.
Dr Astbury, on rounds at 8.30am that day, was not told about a report on Ms Halappanavar's chart flagging up possible inflammation of the foetal membrane.
Had she known she would have terminated, she said.
Her registrar Ann Helps said she does not recall reading the note.
However, experienced midwife Patricia Gilligan claimed it was obvious Ms Halappanavar was a "septic abortion" even before Dr Astbury's arrival.
For Mr Halappanavar, questions remain unanswered.
Why was Dr Astbury not called back to Ms Halappanavar's bedside when she displayed signs of severe sepsis?
The midwife who can answer that crucial issue has been excused from giving evidence.
Mr Halappanavar sat for five of the seven days of hearings, often alone, but listening impassively to witnesses and ensuring his legal team thanked the intensive care team for their "valiant efforts" in trying to save his wife's life.
He publicly forgave Ms Burke over the "Catholic" remark, and accepted the sympathies from staff, many of whom were clearly devastated by the first maternal death in the Galway hospital in 17 years.
The unassuming and private 34-year-old scientific engineer started this battle for justice and answers when he took Ms Halappanavar's body home to her heartbroken parents in India and reported her death by telephone to the coroner.
"It's just gives some comfort that the truth is coming out," he said as he arrived at the hearing.
Belfast Telegraph Digital