A cascade of errors and uncertainty about the law on abortion contributed largely to the tragic death of Indian dentist Savita Halappanavar at an Irish hospital last year, according to an official enquiry report.
The report by Health Service Executive inquiry team chaired by Professor Sabaratnam Arulkumaran, which was released on Thursday, found that the most likely cause of her death was infection -- with the risk of infection and sepsis increasing after her waters broke.
"A cascade of errors and uncertainty about the law on abortion contributed largely to her death," Irish Times said.
Thirty-one-year-old Savita had died of septicaemia in her 17th week of pregnancy at University Hospital Galway in October last year and an inquest into her death held in April heard that she had been denied a potentially life-saving termination on the grounds that Ireland is a "Catholic country".
Her husband Praveen Halappanavar said his wife had repeatedly asked for a termination but was refused because a foetal heartbeat was present.
The HSE report says clinical staff at Galway Hospital failed to properly assess or monitor dying woman's condition. It was found that the diagnosis of sepsis secondary to chorioamnionitis or septic shock should have merited expediting delivery to reduce risk of infection.
"The gravity of the situation was increasing but appears not to have been recognised and acted upon," it said. "The interpretation of the (abortion) law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard," it added.
The review said there had been an over-emphasis on the need to not intervene until the foetal heartbeat stopped and not enough emphasis on the need to focus on monitoring and managing the risk of infection.
Prof Arulkumaran said that if Halappanavar had been his patient in the United Kingdom, he would have performed a termination earlier in order to counter the risk of sepsis. He said the plan in her case had been to "await events", which he said was appropriate so long as it is not a risk to the mother or unborn baby. He said the mother should not have to deteriorate to a point where she was gravely ill and "at death's door".
The case had triggered worldwide outrage and re-ignited calls to re-define Ireland's confusing anti-abortion laws, which demands that doctors treat an expectant mother and her unborn baby as equals.
