A report by the Health Watchdog has found the HSE failed to provide the most basic elements of care to Savita Halappanavar.
The HIQA investigation is the third inquiry to take place into the 31-year-old dentist's death last year.
Savita Halappanavar died on 28 October 2012 at University Hospital Galway, from blood poisoning following a miscarriage
Today's report found there was failure to recognise that Savita was at risk of clinical deterioration, and there was a failure to follow up on blood tests.
It says there were a number of missed opportunities which, if acted upon, may have changed the outcome of her care.
HIQA has also made 34 recommendations to improve all maternity hospitals in Ireland.
