An inquiry, ordered by Ireland’s Health Service Executive, strongly criticises the medical team for failing to take into account Savita’s deteriorating condition, and instead focusing too much on saving the foetus.

The death of Savita Halappanavar in an Irish hospital last October was caused by multiple “failures” in assessing and monitoring her condition by the clinical staff that treated her, according to a high-level inquiry confirming her family’s claim that the young dentist may have been saved had doctors agreed to her repeated request for abortion.

Savita (31), who suffered a miscarriage, bled to death at Galway University Hospital after being refused termination because of Ireland’s strict anti-abortion laws.

In its long-awaited report, the inquiry ordered by Ireland’s Health Service Executive and led by Sabaratnam Arulkumaran, an internationally renowned obstetrician, strongly criticised the medical team for failing to take into account Savita’s deteriorating condition, and instead focusing too much on saving the foetus.

It identified three key factors that led to her death, including failure to recognise the seriousness of her condition and persistent refusal to carry out an abortion. A proper assessment and monitoring would have allowed the clinical team to “recognise and respond to the signs that her condition was deteriorating,” it said.

The inquiry found that a lack of clear guidelines on abortion clouded the professional judgement of those who treated Savita, with the result that there was an apparent overemphasis on the need not to intervene until the fetal heartbeat stopped — and not enough emphasis on the need to focus on monitoring and managing the risk of infection.

“The interpretation of the 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 said.

Dr. Arulkumaran said Savita and her husband Praveen Halappanavar repeatedly inquired about the possibility of an abortion after she was admitted to hospital on October 21. But the doctors refused as under the law they had to be sure that there was a real and substantial risk to the mother’s life. By the time they came to that conclusion it was too late.

“Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have led to reconsideration of the need to expedite delivery,’’ he said.

The report, released on Thursday, came two months after an inquest jury ruled unanimously that Savita’s was caused by “medical misadventure.”

Mr. Halappanavar’s solicitor Gerard O’Donnell complained that the final draft of the report was not shown to his client who was out of the country. “It is very unfortunate and a little disrespectful of Praveen and his late wife,” he said. The report, he said, vindicated his client’s claim that his wife died because of negligence.

“It bears out what my client has always said — the significant shortcomings across the board in the treatment of his late wife Savita. It identifies a number of key causal factors which contributed to, indeed resulted in, her death,” he told Irish Mirror.