A verdict of medical misadventure has been arrived at by the jury in the Savita Halappanavar coroner's inquest in Galway.

Savita was 17 weeks pregnant when she died last October 28 at University Hospital Galway following a miscarriage, after she was refused a termination during the earlier part of her hospitalisation.

The jury endorsed nine recommendaitons made by the coroner, Dr Ciaran MacLoughlin, which will have major implications for the future obstetric practice of individual doctors and of hospitals and for the Govdernment in terms of bringing legal clarity to the termination issue.

The first of the recommendations is that the Medical Council should lay out exactly when doctors can intervene to save a mother's life in order to clarify this issue, which has been at the heart of the Halappanavar case.

The jury also backe the Coroner's recommendations that blood samples should always be followed up to minimise errors; that proper sepsis management training and guidelines are available to staff; and that there is proper communication between staff on call and those coming on duty in hospitals.

The recommendations also include that each hospital in the country should have a  has a protocol for sepsis management and that that modified early warning score charts are introduced in all hospitals as soon as possible.

The HSE has been planning but has yet to introduce such an early warning system for maternity care of seriously ill patients.

The Coroner also recommended that and that there should be effective communication between patients and relatives to ensure they are fully aware of treatment plans.

It was also recommended that medical and nursing notes be kept separately and that no additions be made to notes where the death of a person will be subject to an inquest. The inquest had heard that some additions were made to Savita's medical notes after her death.

Today's verdict of medical misadventure has no bearing on apportioning legal liability under civil law in the case.

Dr McLoughlin pointed out that under the current legal situation relating to termination,doctors who acted in good faith but were found to have breached Medical Council guidelines on termination could be subjected to criminal sanctions and faced 'a path of ignominy and shame'.

The Medical Council, he said, should convey in its guidelines when a doctor is permitted  to intervene to save the life of a woman by carrying out a termination.

The Government, which has pledged to introduce legislative change and regulations to clarify medical practice in this area, has promised a bill on the abortion issue will be produced in this Dail term.

The jury's verdict was unanimous and was reached after two hours and 40 minutes of deliberation.

Dr MacLoughlin expressed his sincere and deepest sympathies to Praveen Halappanavar.