A report from the third investigation into the death of Savita Halappanavar has found a failure in the provision of "the most basic elements" of care to her.
Health Information and Quality Authority (HIQA) launched its inquiry last November and looked at the safety, quality and standards of services provided by the Health Service Executive (HSE) to patients, including pregnant women, at risk of clinical deterioration.
Savita died at University Hospital Galway (UHG) last October one week after being admitted suffering a miscarriage.
The Director of Regulation at HIQA, Phelim Quinn, said "They identified a failure to recognise that she was developing an infection and then a failure to act on the signs of her clinical deterioration in a timely and appropriate manner".
He says that of the 19 recommendations they have made nationally, the most important is to improve how hospitals manage infections.
HIQA also identified a number of missed opportunities to intervene which, if they had been acted upon, may have resulted in a different outcome for Savita. They say it was clear that UHG did not have effective clinical arrangements in place to ensure regular monitoring was done.
The investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which HIQA says were not consistent with best practice. The investigation also identified that there there is no centralised and consistent approach to data collection sources involved in collecting maternal morbidity and mortality data.
Dr. Nuala Lucas is from the investigation committee of HIQA. She said there were comprehensive failings in how Savita was treated.
A statement on behalf of University Hospital Galway has apologised to her husband Praveen and her family.
CEO of West/North West Hospitals Group Bill Maher said "The board and management of the West/North West Hospitals Group are determined to ensure the safety and welfare of all patients attending UHG and the other six hospitals in our newly established Group".
"Now that this third investigation is complete, a special board meeting next week will consider all of the findings and recommendations and identify what further action needs to be taken".
"We have already made considerable progress in implementing the recommendations from the HSE investigation and the coroner’s inquest" he added.
Authority has made 34 recommendations to improve Irish maternity hospitals
HIQA says because there is wide variation in the local clinical and corporate governance arrangement across Irish public maternity hospitals, "it is impossible at this time to properly assess the performance and quality of the maternity service nationally".
One of the key recommendations from the investigation is the need for the development and implementation of a National Maternity Services Strategy. HIQA says this will move Ireland towards a high quality, safe and best practice model of maternity care.
HIQA also draws similarities to findings relating to the Health Service Executive (HSE) inquiry into the death of Tania McCabe and her son Zach in 2007. It says the circumstances of this have a "disturbing resemblance to the case of Savita Halappanavar".
It says it is "simply unacceptable" that six years on from the McCabe report, only 5 out of the 19 public maternity hospitals were able to provide details on the implementation of that report's recommendations.
The Authority has made 34 recommendations to improve all maternity hospitals in Ireland.
These include the need to review and improve maternity services in respect of the management of sepsis, clinically deteriorating pregnant women, patient choice, models of care and providing a suitably skilled and competent workforce that can deliver safe and effective care at any given time.
