The jury in the Savita Halappanavar inquest has made an official ruling of “medical misadventure” and have also endorsed the coroner’s nine recommendations for abortion laws in Ireland.

The jurors have been listening to the evidence regarding the death of the Indian dentist in Galway, who died 17 weeks into her pregnancy following a miscarriage. Medical misadventure, the ruling made today, was defined by the coroner, Dr. Conor MacLoughlin, as displaying “system failures or deficiencies” in her medical care before she died, according to the Irish Independent.

According to RTÉ News, the Medical Council has supported nine recommendations made by Dr. Conor MacLoughlin that have also been included as a result of the inquest. The first of these includes laying out exactly when a doctor would be allowed to intervene to save the life of a mother.

Savita's husband, Praveen, who attended some of the inquest.

They also endorsed recommendations that blood samples are always followed up to make sure errors do not occur and proper sepsis and management training is available to all staff.  The jury also recommended that proper communication channels remain open between staff going off duty and those coming on duty.

Other recommendations made by the jury suggested early warning score charts are introduced in hospitals, that there is a protocol for sepsis treatment and communication remains open between patients and relatives, ensuring the family are aware of their treatment plan.

On top of the above, nurse notes and medical notes are to remain separate and there are to be no additions made to notes if the person who has died will be the subject of an inquest.

An early statement from the coroner in the case had stated that no person, or persons would be blamed for the outcome, regardless of the verdict.