THE draft report into the tragic death of expectant mother Savita Halappanavar at Galway University Hospital last October makes for sombre reading, and will mean heartache revisited for her husband, Praveen, and her wider family.
The report, part of which was leaked yesterday, raises a whole new set of questions surrounding the medical care Savita received after she was admitted to the hospital while 17 weeks pregnant with severe back pain.
Her death became international news and put Ireland in the headlines for all the wrong reasons. The word went around the globe that a 31-year-old perfectly healthy woman who was miscarrying died when she was refused an abortion, allegedly because of the religious ethos of this country.
The focus since her death has been on our failure to legislate for the X case 20 years after the passing of a constitutional amendment to allow for abortion when the life of the mother was threatened.
But a litany of failures surrounding Savita's care outlined in the draft HSE inquiry into her death widens the focus beyond the abortion issue and puts the spotlight on the health service and the standard of care afforded patients.
A picture is painted of staff under pressure working in a frantic environment, and confusion over the following of procedures. It begs urgent action from Minister for Health James Reilly and health officials.
The draft report, leaked to the 'Evening Herald', says Savita's request for a potentially life-saving abortion should have been considered days before her death.
It reveals that crucial signs that Savita had an infection were initially missed by hospital staff, with no follow-up to tests showing possible blood infection on the day she was admitted to hospital, October 21.
There was a lack of clarity among staff about who was responsible for acting on these blood test results, with the registrar telling the junior doctor to do it and the junior doctor thinking it was the registrar's duty.
This is despite the fact that the blood tests showed an elevated white cell count which is a red flag for suspected blood poisoning, a potentially life-threatening complication.
There is no record of a review of pulse, blood pressure, temperature or the ordering of any investigations to check for the early possibility of infection.
In an extremely worrying finding, the draft report says doctors were often too busy caring for other patients to deal immediately with Savita, whose condition was growing progressively worse as time went on.
It found that a lack of knowledge about quick-fire techniques to make a diagnosis of blood poisoning was an issue.
The country was shocked at the death of a happy and healthy young woman. Savita and her husband, Praveen, both from India, had made a life in Ireland and were very popular with their colleagues and in their community. Becoming parents for the first time was hugely important to them.
Instead of experiencing the joy of birth, they found themselves living a nightmare and being thrown into the middle of an ethical and legal minefield which exists due to the decades-long failure of politicians in this country to tackle the abortion issue.
While Praveen will have to live with his devastating loss for the rest of his life, the one good thing that has come out of Savita's death is that, finally, politicians have been moved to take action on the X case.
There were public hearings in early January with submissions and views from a cross-section of medical people, politicians and campaigners. The hearings, under the excellent stewardship of Fine Gael TD Gerry Buttimer, were seen as a fine example of parliamentary democracy at work. With those hearings behind it, the Government remains committed to legislation for the X case with regulation.
IT is clear from the draft findings of the HSE inquiry into Savita's death that the focus has to be as much on practices and procedures in our hospitals as on the law and the constitution.
In addition to its commitment to legislation, the Government and Dr Reilly must look long and hard at how our major hospitals operate when medical emergencies arise, and whether or not their inadequacies are a result of budgetary cutbacks or operational deficiencies in the system.
Taoiseach Enda Kenny stressed yesterday that the report is not finalised and that the priority should be to explain the findings to Praveen Halappanavar before it is made public.
But the fact is that the report's findings are now in the public domain. The rights or wrongs of the leaking of the report are only a side show. The full report should now be released with haste.
The priority should be to get the full facts out there, and that action be taken immediately to ensure that no other patient in this country has to endure the litany of failures that Savita did.