An official HIQA report into the death of Savita Halappanvar has found a series of failures in the provision of basic medical care.
The report finds that staff in University Hospital Galway failed to recognise Mrs Halappanavar's original infection and deterioration.
It says there were 13 missed opportunities to detect her deterioration which may have changed the outcome of her care if they had been acted upon.
The report makes 34 recommendations for maternity services both in Galway and nationwide.
Dr Nuala Lucas from HIQA's investigation committee said there were comprehensive failings in how Savita was treated:
Meanwhile on a national level, HIQA has found that there is wide variation and inconsistencies in how the 19 maternity hospitals across the country are being run.
The report says only 8 of those hospitals produce any annual clinical report, and it’s impossible to properly assess the performance and quality of maternity services.
HIQA is recommending a national strategy for maternity services to make sure the HSE delivers care that is high quality, safe and best practice.
HIQA’s Director of Regulation Phelim Quinn says they’ve made 19 recommendations nationally - the most important is to improve how hospitals manage infections.
