A report into the death of Savita Halappanavar and related issues has found a failure to provide the most basic elements of care in her case.
The pregnant 31-year-old died in an Irish hospital in October last year.
She had asked for a termination after being told she was having a miscarriage, but staff refused. Days later, she died from infection.
A 257-page report by the Health Information and Quality Authority (HIQA) was issued on Wednesday.
It found there were many missed opportunities, that if acted on might have changed the outcome for her.
The report was conducted after the HIQA was asked by the Republic of Ireland's Health Service Executive to investigate the safety, quality and standards of services provided at University Hospital Galway.
Mrs Halappanavar died one week after she was admitted to the hospital when she was 17 weeks pregnant and miscarrying.
Wide variations in care
The report also revealed wide variations in clinical care in the country's 19 public maternity hospitals and units.
It stated there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, as well as no centralised approach to reporting maternal morbidity and mortality.
As a result, it is impossible to properly assess the performance and quality of maternity services nationally, the report found.
In the case of Mrs Halappanavar, the report said there was a failure to recognise she was developing an infection and to act on her deteriorating condition.
It found that University Hospital Galway did not have effective arrangements to regularly record and monitor her condition and that the management of the delivery of maternity services was not consistent with best practices.
The report stated the findings in the Halappanavar case bore a disturbing resemblance to the findings of an HSE inquiry into the death of Tania McCabe and her son Zach, in 2007, at Our Lady of Lourdes Hospital in Drogheda, County Louth.
The HIQA made 34 recommendations on improving the care of clinically deteriorating pregnant women.
It also called for a national maternity services strategy to ensure women receive safe, high quality and reliable care.
The inquest into the death of Mrs Halappanavar took place in April and found she had died due to medical misadventure.
An HSE clinical review report was published in June, which found inadequate assessment and monitoring and a failure to recognise the gravity of the situation and the increasing risk to her life.
Her husband Praveen has initiated legal action against the HSE.
Speaking at the publication of the report, HIQA director of regulation Phelim Quinn extended his sympathies to Mr Halappanavar.
He said the report would be "a further difficult read" for him and his family.
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