The doctors were found to be at fault in multiple ways:
The Health Service Executive (HSE) and Health Information and Quality Authority (HIQA) conducted an investigation. Both criticized the team for not diagnosing the sepsis soon enough and for not using already-standard screening tools for detecting and managing maternal sepsis, and for poor keeping of medical records, poor communication at shift changes, and failure to notify staff with needed expertise, and criticized the administration of the hospital for the poor system in which the team failed. They made recommendations about training and policies for the hospital locally along with a number of national recommendations, including the creation of a laboratory system to coordinate a national response to emerging microbial threats.The HSE also recommended changes to the legal situation and training of doctors about the law.
The law in force at the time stated that the act of abortion, where there was no immediate physiological threat to the woman's life to continue the pregnancy, was a criminal offence punishable by life imprisonment. Following a ruling of the Supreme Court of Ireland in 1992 – now known in Ireland as the X case – terminations are allowed under certain circumstances, where "a pregnant woman's life is at risk because of pregnancy, including the risk of suicide".[14] However at the time of Halappanavar's death, there was legal uncertainty regarding the precise circumstances in which this exception to preserve the life of the mother would apply in practice, as the matter had not yet been enacted in legislation.
the jury returned a verdict of medical misadventure.
The doctors and nurses were poorly trained. They did not communicate properly.
Earlier, the consultant obstetrician who treated Mrs Halappanavar has told the inquest there was a "systems failure" in the care that was given to her.
Dr Katherine Astbury said Mrs Halappanavar's clinical signs were not checked every four hours after her membranes ruptured, which was a breach of hospital policy.
She told the inquest that when Mrs Halappanavar requested a termination from her on the morning of 23 October, she outlined the legal position to her.
She said that Mrs Halappanavar had told her she was finding it very upsetting and difficult given that the ultimate outcome would be that her baby would not survive.
Dr Astbury told her "in this country it is not legal to terminate a pregnancy on the grounds of poor prognosis for a foetus".
She said it was her view that Mrs Halappanavar was emotionally disturbed, but not physically unwell.
She told Mr Halappanavar's barrister, Eugene Gleeson, that she felt at the time the prospect of viability for the foetus was poor as opposed to being non-existent.
The phrase "inevitable miscarriage" had been recorded in medical notes by a colleague of Dr Astbury on 22 October.
Dr Astbury told Mr Gleeson that "the law in Ireland does not permit termination even if there is no prospect of viability".
She said this was her understanding based on the X Case judgment and Medical Council guidelines.
Dr Astbury told Mr Gleeson it did not occur to her to consult her colleagues about the legal position.
The doctor was not in a terrible position of thinking she would be imprisoned for 20 years. Rather 'it did not occur to her to ask'.
And the midwife:
The midwife manager on St Monica's Ward at Galway University Hospital has confirmed that she told Savita Halappanavar that a termination could not be carried out because Ireland was a "Catholic country".
The malpractice here was not a case of good doctors and nurses hamstrung by terrible laws, but religious bigotry, probably with a good dose of racism, and shitty medical practice.