The consultant at the centre of the treatment of an Indian dentist who died in an Irish hospital after a miscarriage has admitted there were system failures in her care.
Savita Halappanavar was 17 weeks pregnant when she was admitted to University Hospital Galway on Sunday October 21 and died a week later.
Consultant obstetrician Dr Katherine Astbury told an inquest she was unaware of blood test abnormalities as they had not been passed on to her team from the weekend staff on-call.
She also confirmed Mrs Halappanavar's clinical signs were not checked every four hours after her membranes ruptured in the early hours of Monday morning, which was a breach of hospital policy.
And she revealed that on the day the patient finally miscarried - Wednesday October 24 - she did not know a junior colleague had put on her chart that he suspected Mrs Halappanavar was suffering from sepsis caused by chorioamnionitis, an infection of the foetal membrane.
The senior medic was asked by Galway coroner Dr Ciaran MacLoughlin if aspects of Mrs Halappanavar's care could be seen as system failures.
"Yes," she replied.
Mrs Halappanavar, 31, was rushed to intensive care within hours of the delivery, where she remained in a critical condition until her death from a heart attack caused by septicaemia due to E coli.
Dr Astbury has denied she refused Mrs Halappanavar's pleas for a termination a day earlier because "Ireland is a Catholic country".
The medic told her inquest that she could not induce delivery when asked as there was not a risk to Mrs Halappanavar's life and she was restricted by Ireland's abortion law.