Last year, Rewire reported on the tragic and wholly preventable death of Savita Halappanavar at Galway University Hospital. Halappanavar, a dentist who was pregnant with her first child, was admitted to the hospital with severe back pain. She was in the midst of miscarrying a non-viable fetus in a much-wanted pregnancy.

Over the course of three days, Halappanavar experienced an incomplete miscarriage that resulted in a life-threatening infection and unbearable pain. Halappanavar and her husband begged doctors to terminate the pregnancy. The doctors refused because, as she was told by the hospital’s midwife manager, Anna Maria Burke, “Ireland is a Catholic country.”

And in that Catholic country, where a woman’s life is secondary to a non-viable fetus, the woman died.

Now, a report by the Health Service Executive has concluded, according to the Irish Times, that there was “an overemphasis by hospital staff on the welfare of Ms Halappanavar’s unviable foetus and an underemphasis on her deteriorating health.”

As reported by the Times, the report says, “The investigating team considers there was an apparent overemphasis on the need not to intervene until the foetal heart stopped, together with an underemphasis on the need to focus an appropriate attention on monitoring for and managing the risk of infection and sepsis in the mother.”

The final draft of the report did not mention the widely quoted comment by Burke about Ireland being a “Catholic country” where doctors would not end a miscarriage, but Burke admitted to saying this during testimony.

Reading reports of testimony provided during the inquest left me feeling the panicked helplessness I can only imagine that Praveen Halappanavar felt as his wife lay dying from a preventable and treatable condition that was treated as subordinate to a pregnancy that could not succeed. Reading the details of their ordeal is difficult even for a complete outsider.

According to both the timeline of Halappanavar’s “care” and reports by clinicians who evaluated the records, it is clear that infection had already set in when Savita was admitted to the hospital, but tests revealing elevated white blood counts were “not immediately relayed” to her doctors.

According to experts interviewed by the Times, the key issues arising from the report revealed that “on admission to the Galway University Hospital on Sunday, October 21st, Ms Halappanavar’s white blood-cell count was elevated, which indicated her body was fighting an infection.”

It finds her vital signs were inadequately monitored; that she was seriously ill by the evening of Tuesday 23rd, but that this was not acted on; that her team saw her on the morning of Wednesday 24th and she had further deteriorated, and still this was not acted on adequately; that further blood samples were not taken until later that day and that the High Dependency Unit did not get involved until the Wednesday evening, after the foetal heartbeat had stopped.

In a subsequent article, the Times reports that Dr. Susan Knowles, a consultant microbiologist at the National Maternity Hospital who testified at the inquest, “was also critical of poor documentation at a critical time in Ms Halappanavar’s care on Wednesday, October 24th last.”

Moreover, the report notes that “the possibility of performing an abortion was discussed by the medical team on the Wednesday. Mr Halappanavar was unaware this had been discussed. The couple’s request for a termination on the Tuesday is acknowledged in the report, but not in Ms Halappanavar’s medical notes.”

So doctors and nurses knew they had a non-viable fetus, they knew they had a woman at high risk of death, and they must have known that time was of the essence.

And yet they did not act.

This is the inevitable outcome of abortion bans. Women die.