University Hospital Galway (UHG) failed to provide the most basic elements of care to Savita Halappanavar, the latest damning inquiry into the circumstances of her death 12 months ago has found.

The newly-published report of the probe by the safety watchdog HIQA identified a number of missed opportunities to intervene in her care which, if acted upon, may have resulted in a different outcome and saved her life.

The report has also identified deficits in the provision of maternity services nationally, with a number of concerns expressed in the report about the implementation of safety standards in maternity units.

In particular, the report says many maternity units have not properly implemented 2007 recommendations on dealing with seriously ill maternity patients issued following the death of Tania McCabe from septic shock at Our Lady of Lourdes Hospital in Drogheda.

The report also points to staffing and resource shortages at UHG to effectively deal with emergency maternity cases.

HIQA's Director of Regulation Phelim Quinn said there had been a failure to recognise that Savita was developing an infection and then a failure to act on the signs of her clinical deterioration.

Savita was 17 weeks pregnant when she died as a result of sepsis on October 28, 2012 at University Hospital Galway following a miscarriage.

HIQA said while Savita died from sepsis, it could not find a nationally- agreed definition of maternal sepsis and also found inconsistencies in the recording and reporting of maternal sepsis nationally.

HIQA said in the Savita case, UHG did not have effective clinical arrangements in place to ensure regular monitoring of the patient, acting on any danger signs and having a seamless clinical handover of information relating to each patient within and between clinicians and clinical teams.

"Our investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which were not consistent with best practice," Mr Quinn said.

He said there had been a series of missed opportunities to intervene in Ms Halappanavar's care pathway which, if acted upon could have changed the outcome for the patient.

The report states that there was a failure on the part of Savita's clinical team to recognise that she was at risk of clinical derterioration and developing sepsis.