MEDICS treating Indian dentist Savita Halappanavar, who died after being refused a termination as she miscarried, failed to give her the most basic care, a damning review of her case has found.
Watchdog the Health Information and Quality Authority (Hiqa) said that doctors failed to recognise that she was suffering from an infection and failed to act on signs that she was deteriorating.
Director of regulation Phelim Quinn said there were a series of missed opportunities in Mrs Halappanavar's care in University Hospital Galway.
"The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar," he said.
"Effective care and treatment depends on the regular monitoring and recording of a patient's clinical observations and recognising their significance, acting appropriately on the findings, escalating concerns and the seamless clinical handover of information relating to each patient within and between clinicians and clinical teams."
Key findings of the Hiqa report included:
*General lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in Mrs Halappanavar's case.
*Failure to recognise that Mrs Halappanavar was at risk of clinical deterioration.
*Failure to act or escalate concerns to an appropriately qualified clinician when Mrs Halappanavar was showing signs of clinical deterioration.
It is the third inquiry into Mrs Halappanavar's death from sepsis.
Investigations were also carried out by a coroner and the Health Service Executive (HSE).
Last April, the coroner found Mrs Halappanavar died because of medical misadventure while the HSE inquiry highlighted a number of failures by medics looking after her.
The Hiqa report examines the safety, quality and standards of HSE care for critically ill patients, including pregnant women, whose condition is getting worse.
Praveen Halappanavar, Savita's widower, is taking legal action against University Hospital Galway over alleged breaches of medical practice.
Mrs Halappanavar died in the Galway hospital on October 28 last year. She was 17 weeks pregnant when she was admitted a week earlier, having a miscarriage. She also suffered septicaemia.
The Hiqa inquiry has found that ultimate clinical accountability rested with her consultant obstretrician, Dr Katherine Astbury.
It stated that Dr Astbury was the most senior clinical decision-maker treating Mrs Halappanavar and should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly.
"Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar's care," Hiqa stated.
Hiqa issued a damning verdict on the medical staff at the hospital.
It said the consultant, non-consultant hospital doctors and midwifery and nursing staff were responsible and accountable for ensuring Mrs Halappanavar got the right care at the right time but they did not.
Hiqa criticised the record keeping at the hospital and the management of patients attending obstetrics clinics.
In Mrs Halappanavar's case it found evidence of a number of retrospective entries into her notes two weeks after her death - an issue which had been raised at an inquest into her death but that the coroner Ciaran McLoughlin found did not have any material bearing on how and why she died.
Other findings from Hiqa include:
* Vital hospital policies were not in use nor were arrangements to ensure basic patient care on St Monica's Ward, such as observation of obstetric patients.
* Early warning score charts were not used in the ward.
* There was no formal clinical escalation protocol and no emergency response team at University Hospital Galway.
* Consultant obstetricians on-call in the hospital's labour ward were not present in the ward but off doing other duties - against the best national and international evidence.
Meanwhile, the hospital which treated Ms Halappanavar issued an apology in light of the report.
Bill Maher, the Group Chief Executive of the West / North West Hospitals Group, said:
"On behalf of University Hospital Galway, I would like to apologise to Mr Halappanavar and family for the events related to his wife's care that contributed to her tragic death and to offer our sincere sympathies to all concerned.
"The board and management of the West / North West Hospitals Group are determined to ensure the safety and welfare of all patients attending UHG and the other six hospitals in our newly established Group.
Hiqa said there was a "disturbing resemblance" between Mrs Halappanavar's death and the case of Garda Sergeant Tania McCabe, who died in 2007 along with one of her newborn sons shortly after giving birth to twins.
"What is critically important is that we must learn from this tragic event and ensure that the findings, learning and recommendations of this investigation, and of the HSE inquiry, are effectively implemented across the health service," the report concluded.
"This investigation clearly shows that where responsibility for implementation of learning is not clearly owned, then learning nationally does not happen, as demonstrated in the findings relating to the HSE inquiry into the death of Tania McCabe and her son Zach in 2007, the circumstances of which have a disturbing resemblance to the case of Savita Halappanavar."
Hiqa has called on the Galway Roscommon Hospital Group to consider the actions, omissions and practices of the nurses and doctors who treated Mrs Halappanavar and refer them to professional regulatory bodies if necessary.
"Patients and members of the public are entitled to expect the highest level of healthcare. When the delivery of care falls below that level, they are entitled to ask why and be assured that measures have been taken to protect them and future patients from harm," it said.
The Health Service Executive (HSE) has been ordered to review staff numbers for national maternity services to ensure teams have sufficient staff with the right mix of skills and deployed effectively in day time and for on-call hours.
Separately the HSE and Department of Health have been told to prioritise a review of national maternity services and put together an agree standard of care and support for pregnant women on a 24-hour basis.
Ireland has boasted one of the lowest maternal death rates in the world with the figure down to eight per 100,000 births in 2009 and 2010.
But Hiqa said it has found that maternity services may not be as safe as they should be or of sufficient quality and that needs to be urgently addressed.
Inspectors found 13 missed opportunities where medics failed to spot the significant deterioration in Mrs Halappanavar's condition from the time she was admitted on the Sunday and a diagnosis of septic shock was made the following Wednesday.
All hospitals and maternity units must learn from these signs, Hiqa said.
Elsewhere, it revealed that during this probe it found only five of 19 maternity hospitals or units were able to provide a detailed status update on recommendations they were ordered to implement following Mrs McCabe's death.
On a national level, investigators revealed wide variations in clinical and corporate governance arrangements across the 19 maternity hospitals/units.
It maintained that it is impossible to assess the performance and quality of the national maternity service because of inconsistencies in governance structures and in the quality of services at each hospital.
It also raised concerns over the lack of evidence of any national review, or national population-based needs assessment, undertaken to demonstrate the appropriate allocation of resources for the provision of maternity services in Ireland.
In total 34 recommendations have been issued to health chiefs in the hope of preventing a repeat of Mrs Halappanavar's death.
By Ed Carty and Brian Hutton