THE jury in the inquest into the death of Savita Halappanavar has returned a unanimous verdict of medical misadventure and has endorsed the coroner's nine recommendations.
Mrs Halappanavar dies last October at Galway University Hospital following a miscarriage. She was 17 weeks pregnant.
Coroner Dr Ciaran MacLoughlin said that the Medical Council should lay out exactly when doctors can intervene to save the life of a mother.
Outlining the first of his recommendations, he said that this would provide clarity for patients and doctors.
Among the other recommendations endorsed by the jury were:
- that blood samples are always followed up to ensure errors do not occur;
- that proper sepsis management training and guidelines are available for hospital staff;
- that each hospital in Ireland has a protocol for sepsis management;
- that modified early warning score charts are introduced in all hospitals as soon as possible;
- that there is effective communication between patients and relatives to ensure they are fully aware of treatment plans.
- that there is effective communication between staff on call and those coming on duty in hospitals.
The final two recommendations are that medical and nursing notes are kept separately and that no additions are made to notes, where the death of a person will be subject to an inquest.
The 11-member jury deliberated for two hours and 40 minutes.
Addressing widower Praveen Halappanavar, Dr MacLoughlin said, "all of Ireland had followed the story" and he offered his sympathies on behalf of the country.
The coroner also clarified that the verdict of misadventure does not mean deficiencies or systems failures contributed to the death of Mrs Halappanavar.