An expert witness has identified shortcomings in the way Savita Halappanavar was treated at Galway University Hospital as her condition deteriorated.

Consultant microbiologist Dr Susan Knowles has told the inquest that there was poor documentation of the patient's worsening condition.

She said most medical notes from a crucial period of the onset of sepsis were made retrospectively.

Some were made shortly after the events of the afternoon of Wednesday 24 October, but others were added on 7, 8 and 12 November.

Dr Knowles said a white cell count reading from blood test results should have been checked to alert staff that she had more severe sepsis than initially thought.

When Mrs Halappanavar complained of feeling cold and shivery at 4.15am on the morning of 24 October, all her vital signs should have been recorded. This did not happen.

Dr Knowles said that when she was diagnosed to be clinically septic at 6.30am that morning, she was examined promptly and that intravenous antibiotic treatment followed.

This treatment should have been actively followed up after ward rounds at around 8.20am.

Dr Knowles said the management of Mrs Halappanavar's condition from 1pm that day was of a high standard.

Dr Knowles told counsel for Praveen Halappanavar, Eugene Gleeson, that it is important that blood test results are followed up.

She said the team of medics caring for Mrs Halappanavar should have been aware of an elevated white cell count reading sooner than was the case. This is one of the indicators for the presence of sepsis.

Dr Knowles said the pattern of vital signs in the case of Mrs Halappanavar were also important.

They should have all been monitored and recorded. This did not happen.

She told Mr Gleeson the observation chart was very important for patients generally. In this case, she said it was "hugely important" and "tells a lot of the story".

She agreed that it was clear that the GUH protocols for dealing with sepsis infection had not been adhered to.

Dr Knowles said the antibiotics recommended as part of those guidelines had not been administered until around 1pm on Wednesday 24 October.

Dr Knowles is the consultant microbiologist at the National Maternity Hospital in Dublin.

The inquest has been adjourned until next Wednesday.

Delay in review of blood tests

Counsel for Galway University Hospital Declan Buckley has been providing clarification about two blood tests carried out on Mrs Halappanavar.

The first test was conducted after the 31-year-old was admitted to hospital on the afternoon of Sunday 21 October.

The bloods were received in the laboratory at 6.33pm that evening and immediately processed.

Results were authorised and available for review on the hospital's computer system at 6.37pm.

These results showed an elevated white cell count, one of the indicators for sepsis.

They were first reviewed at 5.24pm on Monday 22 October by an unidentified member of staff.

The results were next accessed by an individual at 8.21am on the morning of Wednesday 24 October.

By this time, sepsis had been diagnosed in Mrs Halappanavar and her condition had deteriorated significantly.

Mr Buckley told the inquest these results were reviewed several times by Dr Katherine Astbury from 11.25am onwards.

A second blood sample was sent to the laboratory at 8.29am on 24 October.

It was processed by 9.54am and first reviewed on the hospital's computer system at 10.36am by an unidentified user.

Dr Katherine Astbury reviewed the results a number of times, beginning at 11.20am.

The inquest also heard that a blood sample taken from Mrs Halappanavar was not subjected to a lactate serum test, which could have confirmed the presence of sepsis.

The sample was taken at 6.30am on Wednesday 24 October. It was stored in an inappropriate bottle and sent to the laboratory.

Mr Buckley said the test in question is carried out at point of care units on individual wards and would not have been carried out by the laboratory in any event.

Dr McLoughlin said one would have thought the sample would have been repeated immediately if it had been noted that it had been sent on the wrong bottle.

He inquired if a phone call had been made to alert the ward that the serum lactate test could not be carried out.

Inquest witnesses recalled

Meanwhile, two witnesses are to be recalled to give evidence to the Mrs Halappanaver inquest to clarify the situation regarding the time and content of a telephone call on the evening of Tuesday 23 October.

Earlier this week, Dr Ikechkwu Uzockwu said he got a call between 9pm and 11pm on the night in question. He was on-call at the Department of Obstetrics and Gynaecology at the time.

When proceedings resumed this morning, Mr Buckley said the doctor was firm in his recollections. Mr Buckley said he was "almost 100% certain" the call was made between 9pm and 11pm.

He said the doctor was even more firm in his belief that the conversation was primarily in relation to Mrs Halappanavar having a bath and did not include any remark other than her vital signs being normal.

He said there were "irreconcilable differences" between the evidence given by Dr Uzockwu and Nurse Ann Maria Burke.

Coroner Ciaran McLoughlin said it was very important that the issue be clarified in the sense that it would be very unusual for a nurse to call a doctor to say a patient's vital signs were normal.

He requested that both witnesses be recalled.

Inquest hears from consultant anaesthetist

Consultant anaesthetist Dr Paul Naughton has given evidence about the final days of Mrs Halappanavar's life.

When Dr Naughton took over her care in the ICU department at 9am on Friday 26 October, she was in septic shock and had multiple organ failure.

He said by that time she had respiratory, cardiovascular and haematological dysfunction.

Given Mrs Halappanavar's age and mental condition, Dr Naughton said he was hopeful, but he conceded that the prognosis was poor.

He said sepsis had set off a cascade of events, leading to an inflammatory reaction that would not stop, even though antibiotics were being administered to kill bacteria.

It proved impossible to reverse this, he said.

Counsel for Praveen Halappanavar has extended his client's eternal gratitude for the efforts he made to assist his wife and for support he provided to him.

Husband finding proceedings stressful

Praveen Halappanavar has decided not to attend today's proceedings.

Ahead of today’s hearing Mr Halappanavar’s solicitor, Gerard O'Donnell, said that his client was finding the proceedings very stressful.

Mr Halappanavar will be attending the inquest next Wednesday when it resumes after today's hearing.

Mr O'Donnell said that Mr Halappanavar felt the inquest was establishing the facts.

The primary role of the inquest is to determine key facts concerning the death of Mrs Halappanavar who died on 28 October 2012 at Galway University Hospital following a miscarriage.

Mrs Halappanavar was 17 weeks' pregnant at the time.

The HSE's draft clinical review into Mrs Halappanavar's death, given to her husband over a week ago, has yet to be published.