It may not be the final version of the HSE's report into how Savita Halappanavar died, but what has emerged so far through a media leak has given us a stark reminder of how serious an incident this death was.
It should be emphasised that what has emerged to date constitute draft findings and could be subject to revisions before the final report is published around the end of this month.
However, the draft leaked to the Evening Herald will undoubtedly provide the basis for what will be in the final report. And these draft findings will in many ways confirm people's worst fears about what really happened in University Hospital Galway last October.
The draft report of the inquiry highlights a litany of serious failures.
The big one, of course, is the failure of our legislators over many years to grasp the issue of abortion and providing legislation and guidelines on this where the mother's life is deemed to be at risk and the tragic effect this can have when serious cases emerge in maternity units.
There will, still, however, be major questions over whether the current legal situation should have contributed to Savita's death.
The findings also clearly show the failure of a major hospital unit to provide safe care to a mother who was seriously ill. The report shows a very worrying deficit in basic hospital procedures and guidelines for treating a very sick pregnant woman.
In addition, the findings show that pressure on hospital staffing and resources, something that is all too prevalent nowadays, can compromise safe maternity care.
The report indicates that on the abortion issue, the account given by Praveen Halappanavar of the events that took place in relation to the refusal of a termination for his wife has been substantially borne out by the findings.
The Halappanavars, according to the report, had asked for medication to induce a miscarriage that they were told was inevitable.
While there is no confirmation of the 'this is a Catholic country', statement, the findings indicate that when a termination was requested, the couple were informed that the current legal situation on termination when the mother's life might be at risk 'tied the hands' of staff as regards performing a termination.
A consultant told the inquiry that under Irish law, if there is no evidence of risk to the life of the mother, the hands of staff are tied if there is a fetal heartbeat. This policy appears to have been followed to a fatal conclusion in the Savita case.
In this context, it should be noted that the report says evidence of a potential risk to Savita's life, blood poisoning, had been missed at an early stage in a test following her admission. A diagnosis of sepsis was missed for three days by hospital staff. Also, Savita appeared had clear physical symptoms of serious infection (temperature, vomiting etc.) that were not acted upon.
It should be noted too that the experts who conducted the HSE inquiry felt that there had been too much emphasis on the fetal heartbeat and not enough on Savita's deteriorating and life-threatening condition.
They felt a termination should have been carried out at an earlier stage of Ms Halappanavar's treatment.
One cannot help but remember the 'pro-life' article 40.3.3 of our Constitution, which got us into the current legal mess, and which states that there should be 'due regard to the equal right to life of the mother'.
The experts concluded that even before the couple requested a termination, the clinical situation indicated a 'significant and increasing risk to the mother' and a termination should have been considered whether or not one had been requested.
The report says without a termination, the prognosis for both the fetus and potentially the mother was poor.
So it appears that the hospital's particular interpretation of the law in this case, coupled with serious flaws in hospital procedures and practices surrounding management of Savita's condition, sowed the seeds of the tragedy.
Quite apart from the controversy of the termination refusal, the findings of the draft report point to major flaws in how University Hospital Galway looked after Ms Halappanavar.
Basically, as with other healthcare scandals, there appear to have been serious deficiencies in delineating who was responsible for what in looking after patients, in staff training and in communications.
There was a lack of clarity among staff members about who was responsible for acting on potentially serious blood test results.
Test showing possible blood infection on the day Savita was admitted were not followed up by staff; there was no record of pulse, blood pressure, temperature or further tests to check for infection; there was an apparent lack of knowledge among staff about diagnosing blood poisoning rapidly and there appeared to be a crucial communication issue between two doctors at a key point in Savita's care.
It is almost inevitable that when the final report is drawn up, it will include a plethora of recommendations for improved guidelines, procedures and training in dealing with severe infection in pregnancy.
This will be welcome, but it will be repeating a pattern of previous scandal reports dealing with major deficits in basic care, often in the care of women patients.
It will inevitably lead to the question - why aren't these vital components in the provision of safe care already in place in hospitals?
Why does it take an 'adverse incident' or incidents, to ensure that , insofar as is possible, hospitals do their jobs properly and safely?
Yes, healthcare staff are only human and errors and omissions can occur, but strong procedural structures and guidelines need to be in place to ensure they are kept to a minimum.
Finaliy, the draft report points to work pressures on staff that may have contributed to the Savita tragedy.
Hospitals have always been under pressure, but following recent severe cuts, they are doing more and more with less and less.
This is all well and good in terms of bean-counting and pleasing the Troika, but if these resource issues are endangering patients, then this poses awkward questions for those running and funding our health system.
Savita probe says abortion was needed
Savita case prompts HSE safety review
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