The husband of an Indian dentist who died after being refused an abortion at an Irish hospital today hit out at her 'horrendous, barbaric and inhuman' treatment.
An inquest jury ruled that Savita Halappanavar's death in October last year was by medical misadventure, and set out a string of recommendations to prevent a repeat of the tragedy.
Speaking after the hearing, her widower Praveen said that University Hospital Galway had left her to die, and did nothing to help her until after she had miscarried their baby.
'It was too late,' he said today - the couple's fifth wedding anniversary. 'The care she received was in no way different to staying at home.
'Medicine is all about preventing the natural history of the disease and improving the patient's life and health and look what they did. She was just left there to die.
'We were always kept in the dark. If Savita would have known her life was at risk she would have jumped off the bed, straight to a different hospital. But we were never told.
'It's horrendous, barbaric and inhuman the way Savita was treated in that hospital.'
Mr Halappanavar says he is considering further action through the European courts, arguing that the hospital breached his wife's right to life.
Mrs Halappanavar, 31, was 17 weeks pregnant when admitted to University Hospital Galway on October 21 last year with an inevitable miscarriage.
She died a week later after suffering a septic blood infection.
The jury at her inquest in Galway courthouse accepted nine recommendations put forward by coroner Ciaran MacLoughlin to prevent a repeat of the incident.
Widower: Praveen Halappanavar arriving at the inquest today, his fifth wedding anniversary
The medical misadventure ruling found that there were systemic failures or deficiencies in the care given to Mrs Halappanavar before she died, although the failures did not directly cause her death.
Her widower Praveen should have been celebrating his fifth wedding anniversary with his wife today.
He was handed a health service internal review of his wife's death on March 30, the day their baby Prasa had been due.
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The nine recommendations are headed by a request for the country's Medical Council to clarify exactly when it is acceptable to intervene in a pregnancy to save the mother's life.
The coroner argues that this will 'remove doubt or fear from the doctor and also reassure the public'.
Other measures include tightening up hospital procedures, by monitoring blood samples, ensuring that shift workers communicate with each other properly, and liaising with patients' families better.
In addition, the jury endorsed plans to aid investigation of contentious cases by keeping two sets of hospital notes and quarantining notes of patients who are being investigated.
Couple: Mr and Mrs Halappanavar pictured on their wedding day before moving to Ireland
After the jury returned their verdict, Mr MacLoughlin spoke to Mr Halappanavar.
'Praveen, I want to offer you my sincerest and deepest condolences on the death of Savita,' he said. 'You showed tremendous loyalty in the love to her during her last week.
'The whole of Ireland has followed your story and I want, on their behalf, to offer our deepest sympathy.
'You will also be watched over and protected by the shadow of Savita who was in our thoughts during this painful and difficult journey.'
Mr Halappanavar, 34, shook hands with the coroner and jury members at the end of the hearing, after his solicitor thanked the coroner for his 'extraordinary sensitivity and logic'.
During seven days of often graphic evidence, the jury heard that Mrs Halappanavar would probably still be alive today if the law in Ireland allowed an abortion, as she miscarried before there was a real risk to her life, by which time it was too late to save her.
Mistakes: University Hospital Galway, pictured, was criticised for its treatment of the patient
Verdict: Jurors unanimously recorded their ruling of death by medical misadventure at Galway Coroner's Court
The Irish government has pledged to publish new abortion laws in July, which will include the threat of suicide as a risk to life and a combination of legislation and regulations for doctors to abide by in cases where there may be uncertainty.
Leading obstetrician Peter Boylan outlined a number of deficiencies in her care, but stressed that none on its own was likely to have resulted in Mrs Halappanavar's death.
JURY'S NINE RECOMMENDATIONS TO REFORM IRISH ABORTION LAWS
The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;
Blood samples are properly followed up;
Protocol in the management of sepsis and guidelines introduced for all medical personal;
Proper communication between staff with dedicated handover set aside on change of shift;
Protocol for dealing with sepsis to be written by microbiology departments;
Modified early warning score charts to be adopted by all staff;
Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;
Medical notes and nursing notes to be kept separately;
No additions or amendments to be made to the medical notes of the dead person who is the subject of an inquiry.
Notes showed that within hours there were mistakes, described by coroner Ciaran MacLoughlin as 'system failures'.
First the blood tests. On admission Ms Halappanavar had an elevated white cell count of 16.9 - a sign of infection. This was not noted on her chart and not investigated by medics who should have repeated the test.
Second, hospital guidelines were broken when her vital signs were not checked every four hours after her waters broke in the early hours of Monday. Those specific checks are designed to spot early signs of infection.
Thirdly, Dr Ikechukwu Uzochkwu disputes claims by midwife Ms Burke that he was told on Tuesday night of high pulse rates, again another sign of infection.
All specialists agreed on the fourth point - Ms Halappanavar was suffering from early stage sepsis when she was found shivering and her teeth chattering at 4.15am on Wednesday. Instead of a doctor being called she was given a blanket and paracetamol.
About 12 hours later severe sepsis had set in and Ms Halappanavar naturally delivered a dead foetus. The tell-tale signs of the infection had been missed, leading to her death days later.
Mrs Halappanavar knew her baby was going to be a girl and had named her Prasa - a symbolism of unity with both their names used to remember her.
Only weeks before, she wept tears of joy at a first scan that confirmed the couple - married five years ago today - were starting a family.
Despite her pain and heartbreak over an inevitable miscarriage, and the onset of sepsis, she still planned to be pregnant again before the due date of her dying baby - less than three weeks ago tomorrow.
Mrs Halappanavar was at the heart of the Indian community in Galway, socialising with friends and organising events, including teaching dance to local youths.
The couple had been friends in the state of Karnataka, south-west India, before Mr Halappanavar moved to Galway in 2006 for a job as a scientific engineer at the medical devices company Boston Scientific.
Each time he returned home their relationship grew stronger and in 2008 they wed in a Hindu ceremony.
Mrs Halappanavar, the only daughter and the youngest of three children, returned to Ireland with her husband within months and spoke to her parents in Belgaum every day on Skype.
Her husband remembered her tears of happiness on the day they first saw their baby girl on the monitor during a hospital scan.