A patient safety system, aimed at alerting health staff when a pregnant woman's condition is deteriorating, is not being operated properly in six out of seven maternity hospitals audited by the HSE.
One of the hospitals which failed to pass the test when audited was University Hospital Galway where Savita Halappanavar died.
The early warning system, which was introduced in maternity hospitals over a year ago, requires a nurse or doctor to repeatedly check a woman's vital signs such as blood pressure, pulse and temperature within set time frames and, based on the score, decide whether to give her urgent care.
The patient chart records the vital signs, giving each a score. The doctor or nurse adds up the score every time the vital signs are recorded, meaning they can recognise immediately the severity of illness and whether the patient needs closer monitoring, or transfer to critical care units. The score depends on how much variation there is in a patient's condition.
Actions can range from calling a senior specialist to examine the patient or urgently transferring them to more specialist facilities for intensive treatment.
It was rolled out in the wake of the tragic case of Ms Halappanavar, who was admitted to University Hospital Galway at 17 weeks pregnant in October 2012. Her worsening condition due to sepsis was missed and she was not treated in time.
The HSE audit carried out between May and August of last year examined how seven of the country's 19 maternity units were operating the early warning score system.
It found the Rotunda Hospital in Dublin was the only one to fully pass the test.
Apart from Galway, deficiencies in practice were found at the Coombe Hospital in Dublin, Cork University Maternity Hospital, Cavan General Hospital, South Tipperary General Hospital and Mullingar Hospital.
The audit of the system, which is also applied to the care of women after having a baby, found it could give "reasonable assurance" that vital signs were appropriately recorded in six of the seven hospitals.
The main failing was that staff were not doing repeat observations of the patient in the recommended time frame after a score which led to some trigger action being reached.
It also highlighted problems with not always recording a score on the patient's chart after each check, while not all staff signed off with their initials as they should.
However, it found the majority of hospitals demonstrated a high level of compliance in ramping up care after the scores indicated risk of critical illness. A draft report was submitted and this is expected to be finalised within the coming weeks.