Health staff's failure to share information is remarkable
It is too late for Savita Halappanavar now but the botched care she received in hospital should send a red alert to health staff across the country.
When Savita's death was first made public last year, the belief was that medical staff knew her life was threatened but could not terminate her pregnancy.
Yesterday, the full catalogue of blunders was laid bare and, although it is not possible to say Savita would be alive today if proper procedure was followed, it is clear the chances of surviving sepsis and not progressing to septic shock dwindled with every passing hour, although she was in hospital for a week.
The inquest confirmed yesterday that the results of the tests, taken on the Sunday of her admission, signalled blood infection but did not trigger a response because of the manner in which they were documented.
This was a vital omission but there were other clues to the potential seriousness of her condition which fell through the cracks in the coming days.
Savita was seen by a series of doctors and nursing staff, but their failure on so many occasions to share information is remarkable. They were oblivious to the danger she was in.
On the Tuesday, Savita had a raised temperature and a midwife said she informed a doctor, who disputes this. There were long gaps between staff monitoring of Savita at night.
By Wednesday morning a doctor noted a deterioration in Savita's condition and wrote it on her chart.
Another junior doctor, who took over duty, was told about Savita's temperature but cannot remember reading his notes.
The doctor may not have mentioned a significant discharge observed in Savita when reading the notes to the senior consultant. That senior consultant in charge of her care also did not read the chart.
Meanwhile, the infection was getting a stronger grip of Savita. When the diagnosis of sepsis was made on Wednesday a decision to terminate the pregnancy was not made until 1.20pm.
She miscarried at 3pm.
The lack of basic care for Savita and inability of the maternity unit to ensure proper systems of investigation, monitoring and sharing of information has given an insight into the circumstances which preceded her death.
Regardless of whether there was legislation in place for the X-case, the fundamentals of good medical practice were seriously deficient.