An Irish hospital staff failed to adequately assess the condition of Indian dentist Savita Halappanavar and missed an early opportunity to terminate her pregnancy, a key report on her death has said.
A clinical inquiry on Savita's death, which was released on Thursday, found that the most likely cause of her death was infection - with the risk of infection and sepsis increasing after her waters broke. It warned that such incidents could happen again in the absence of clarity on abortion law.
31-year-old Savita had died of septicaemia in her 17th week of pregnancy at University Hospital Galway in October last year and an inquest into her death held in April heard that she had been denied a potentially life-saving termination on the grounds that Ireland is a "Catholic country".
Her husband Praveen Halappanavar said his wife had repeatedly asked for a termination but was refused because a foetal heartbeat was present.
The review said there had been an over-emphasis on the need to not intervene until the foetal heartbeat stopped and not enough emphasis on the need to focus on monitoring and managing the risk of infection.
Professor of obstetrics and gynaecology Sir Sabaratnam Arulkumaran, who headed the review commissioned by the Health Service Executive (HSE), said the plan in her case had been to "await events", which he said was appropriate so long as it is not a risk to the mother or unborn baby.
He said the mother should not have to deteriorate to a point where she was gravely ill and "at death's door".
"In this case, we found numerous causal and contributory factors that we believe contributed to this sad and tragic case, and these are outlined in detail in our report.
"We established that the patient was monitored less frequently than required and that guidelines for the prompt and effective management of infection and sepsis were not adhered to.
"We also believe that legislative factors affected medical considerations in this case and that this resulted in a failure to offer all management options to the patient," Arulkumaran was quoted as saying by the Irish Examiner.
The case had triggered worldwide outrage and re-ignited calls to re-define Ireland's confusing anti-abortion laws, which demands that doctors treat an expectant mother and her unborn baby as equals.