The Health Service Executive Clinical Review report into the death of Savita Halappanavar has issued a number of recommendations.
It recommends that there should be prompt introduction of a Maternity Early Warning Scoring Chart system for patients receiving care, for pregnancy complications on gynaecology wards.
The report calls for mandatory induction and education of all clinical staff working in obstetrics and gynaecology, on the early recognition, monitoring and management of infection, sepsis, severe sepsis and septic shock.
It recommends that the HSE should develop and implement national guidelines on infection and pregnancy and the management of early second trimester inevitable miscarriage.
There should also be immediate support for the psychological impact of inevitable miscarriage.
The report also says there is an immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgement can be exercised, in the best medical welfare interests of patients.
Oireachtas should consider legal and clinical guidelines
The Clinical Review report strongly recommends that the Oireachtas considers the law, including any Constitutional change and related legal and clinical guidelines, in relation to the management of inevitable miscarriage in the early second trimester of a pregnancy.
This would include patients with prolonged rupture of membranes and where the risk to the mother increases with time, from when the membranes are ruptured, including the risk of infection, and thereby reduce risk of harm up to and including death.
The HSE investigation team says it noted the evidence that was given to the Oireachtas Joint Committee on Health and Children to discuss the implementation of the Government decision, following the publication of the expert group report on matters relating to the case of A, B & C v Ireland on 8 January last.