SAVITA Halappanavar was the victim of a terrifying catalogue of blunders by hospital staff before dying of a lethal infection.
Doctors caring for the 31-year-old dentist at Galway University Hospital -- whose case re-opened the abortion debate -- seriously failed to investigate, recognise and treat the infection which led to her death.
Her progression to septic shock -- likened to falling off a cliff -- could possibly have been avoided by an early termination of her pregnancy after doctors told her she would miscarry, the report of an independent review of her case revealed.
However, the major failing of the medical team caring for Savita at the hospital is that they underestimated the seriousness of her condition for too long.
They took three days to follow up on crucial blood tests.
Savita was 17 weeks pregnant when she was admitted to the hospital last October 21 and told she would miscarry.
She and her husband Praveen asked for a termination but were told it was not possible because the foetus still had a heartbeat.
Savita died a week later, on October 28, after she suffered septic shock and cardiac arrest.
Referring to the option of terminating the pregnancy, the review team said: "The option of expediting delivery was requested by the patient and her husband and should have been considered whether or not requested by the patient."
The new findings are revealed in a draft report of an independent inquiry team, led by UK obstetrician Professor Aabaratnam Arulkumaran, which is carrying out a clinical examination of Savita's death.
But her husband and family were left "shocked and upset" that they were not provided with a copy of the draft report.
Praveen had previously asked to see the report in order to respond to any inaccuracies it might contain.
His solicitor, Gerard O'Donnell, said: "He's finding the entire incident very traumatic. It's brought a lot back for him. He's too emotional to comment at the moment, but it has been very hard for him."
The Government is expected to examine the final report within 10 days, but Health Minister James Reilly refused to be drawn on the contents of the draft. "I haven't seen it and I don't have it," he said.
The draft report reveals:
* Blood tests were carried out on Savita on the day of her admission but not followed up. The tests showed an elevated white cell count -- a signal for suspected blood poisoning.
* There was a lack of clarity on who was responsible for the follow-up. The senior specialist registrar in obstetrics ordered the tests, but the samples were taken under instruction by a junior doctor who also denied responsibility. A midwife said follow-up was not her job.
* The review team could find no examination of Savita's pulse, blood pressure or temperature to test for early possibility of infection on her second day in hospital.
* There was no review of treatment options, and the pattern was to "await events". Doctors monitored the foetal heartbeat in case "accelerated delivery" might be possible.
* There was over-emphasis on the need not to intervene until the foetal heartbeat stopped.
* On Tuesday her pulse rate at 9pm should have triggered a medical review, but the junior doctor was too busy caring for other patients. He did not attend her until 1am when he carried out a chart review. She was asleep and he did not wake her.
The review team said: "With the possibility of sepsis at this point, help from a senior medic should have been requested."
Although the junior doctor was busy with other patients, this could have been overcome by calling a senior doctor who was on call to see serious cases.
A nurse found Savita cold and shivery at 4.20am and checked her two hours later.
The report was first revealed by the 'Evening Herald'.
It details a difference in recollections of a phone call between a junior doctor and a registrar about Savita's rising temperature that morning.
The registrar did not recall being told of her heart rate and blood pressure, but the junior doctor said he gave the facts but was not told "anything extra".
It was not until Wednesday that a diagnosis of probable sepsis was made and more antibiotics were given.
A diagnosis of septic shock was made later that day and Savita suffered a miscarriage before being transferred to the high-dependency unit.
The following day she was transferred to intensive care and on Friday she was found to be failing. She died in the early hours of Sunday morning after suffering cardiac arrest. The staff interviewed for the review said the option of termination was not possible because of the difficulties with interpretation of the law.
However, the investigation found that even before the family requested the termination, the "clinical situation indicated a significant and increased risk to the mother".
Three inquiries were launched into Savita's death, by the HSE, the Health Information and Quality Authority (HIQA) and an inquest by coroner Ciaran MacLoughlin in Galway.
The HSE inquiry was set up to establish the circumstances leading up to her death and make recommendations to eliminate or reduce the risk of a repeat.
Opposition parties called for the report to be published immediately, but it is likely to be 10 days until this is done.
Health Minister James Reilly said: "I can't make any comment until I have the report because clearly there could be legal issues arising out of this.
"I want to deal with the facts given to me in the report by Prof Arulkumaran, who is near completion. And as far as I know the final drafts are out for consultation."