The jury in the Savita Halappanavar inquest has returned a unanimous verdict of medical misadventure and has endorsed the coroner's nine recommendations.
Mrs Halappanavar was 17 weeks pregnant when she died last October at Galway University Hospital following a miscarriage.
The first of the recommendations is that the Medical Council should lay out exactly when doctors can intervene to save the life of a mother.
Coroner Dr Ciaran MacLoughlin had said this would provide clarity for patients and doctors.
The jury also endorsed recommendations that blood samples are always followed up to ensure errors do not occur; that proper sepsis management training and guidelines are available for hospital staff; and that there is effective communication between staff on call and those coming on duty in hospitals.
Dr MacLoughlin had recommended that a dedicated time should be set aside at the end of each shift for this to happen.
He had also recommended that each hospital in the State has a protocol for sepsis management; that modified early warning score charts are introduced in all hospitals as soon as possible; and that there is effective communication between patients and relatives to ensure they are fully aware of treatment plans.
The final two recommendations are that medical and nursing notes are kept separately and that no additions are made to notes, where the death of a person will be subject to an inquest.
The 11-member jury deliberated for two hours and 40 minutes.
Timeline of Events
Dr MacLoughlin offered his sincere and deepest sympathies to Praveen Halappanavar.
He said he had showed tremendous loyalty and love to his wife during her final days.
Addressing Mr Halappanavar, Dr MacLoughlin said "all of Ireland had followed the story" and he offered his sympathies on behalf of the country.
The coroner also clarified that the verdict of misadventure does not mean deficiencies or systems failures contributed to the death of Mrs Halappanavar.
Mr Halappanavar rose briefly from his seat to thank the coroner.
Arriving for the inquest this morning, Mr Halappanavar said he believed the inquest would answer all the questions he had.
He also said today was a poignant one as it was his wedding anniversary.
Mr Halappanavar said it had been a difficult time for him during the inquest.
But he said he was hopeful of "some bright days ahead" and that something good would come from the process.
He also thanked the coroner for his work throughout the inquest.
Reaction to verdict
The Chief Operating Officer at the Galway Roscommon Hospital Group has acknowledged that there were lapses in the standards of care provided to Mrs Halappanavar.
Speaking after the conclusion of the inquest, Tony Canavan said the deficiencies identified during the inquest would be rectified by the hospital and that all recommendations made by the coroner would be taken on board.
Mr Canavan said some of the recommendations had already been acted on.
In addition he said that the hospital would promptly implement all recommendations made by the HSE and HIQA reports into the death of Mrs Halappanavar.
Mr Halappanavar's solicitor Gerard O'Donnell said the effect of all the shortcomings identified during the inquest had a significant impact on Mrs Halappanavar.
He said the evidence demonstrated a serious and shocking mismanagement of the patient at Galway University Hospital.
Mr O'Donnell said she had been denied and deprived of proper medical treatment when it was urgently needed.
He said no intervention was made until such time as the foetal heartbeat stopped and when intervention came, it was from staff at the hospital's intensive care unit.
The solicitor said it was extremely worrying to think that Irish women suffering from sepsis would have to wait until they were gravely ill before an intervention could occur.
He urged the Government to look at the issue and to introduce legislation, if needed, urgently.
Mr O'Donnell said Mrs Halappanavar was denied of her constitutional right to life and was the victim of a significant breach of human rights.
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