An Indian dentist who was denied an emergency abortion at an Irish hospital last autumn died due to medical misadventure, her inquest has found.
A jury sitting in Galway reached a unanimous verdict in the case of Savita Halappanavar, 31, who died from sepsis, a severe blood infection, after suffering a miscarriage.
The jury endorsed nine recommendations of the coroner, Dr Ciaran McLoughlin. Offering his condolences to Halappanavar's widower, Praveen, MacLoughlin said: "You showed tremendous loyalty and love to your wife. All of Ireland followed the case."
Halappanavar had been 17 weeks pregnant before she died on October 28, 2012 at Galway University hospital. Her plight became the focus of a global outcry over Ireland's strict anti-abortion laws, which the government plans to reform.
The first of McLoughlin's recommendations was that the Irish Medical Council should lay out exactly when doctors can intervene to save the life of a mother. The coroner said this would provide clarity for patients and doctors.
The jury also endorsed recommendations that blood samples should always be followed up to guard against errors; that proper sepsis management training and guidelines should be available for hospital staff; and that there should be effective communication between staff on call and those on duty in hospitals. MacLoughlin recommended that a dedicated time should be set aside at the end of each shift for this to happen.
He said each hospital in the state should have a protocol for sepsis management; modified early-warning score charts should be introduced in all hospitals as soon as possible; and there should be effective communication between patients and relatives to ensure clarity over treatment plans.
The final two recommendations were that medical and nursing notes should be kept separately and that no additions should made to notes where the death of a person will be subject to an inquest.
"I haven't got my answers yet why Savita died. I will get to the bottom of the truth," said Praveen Halappanavar after the jury verdict.
The case last year reignited the debate in Ireland over abortion, after Savita Halappanavar died of septicaemia.
Additional reporting by Bloomberg