The jury in the inquest into a woman who died in hospital in Ireland four days after suffering a miscarriage has given a verdict of medical misadventure.
Savita Halappanavar, 31, died in University Hospital Galway last October.
Her family claimed she might have survived if she had been given an abortion.
The inquest has heard the cause of death was septic shock and E coli.
The jury's verdict in the inquest was unanimous.
The coroner, Dr Ciaran MacLoughlin, said the verdict does not imply individual failings in systems at the hospital contributed to Savita's death.
The jury endorsed the coroner's nine recommendations.
The coroner's first recommendation was that the Irish Medical Council lay out new guidelines on when doctors can intervene to save the life of a mother.
He said the guidelines would remove doubt and fear among doctors and reassure the public.
Other recommendations are that blood samples are always followed up to ensure errors do not occur; that proper sepsis management training and guidelines are available for hospital staff and that there is effective communication between staff on call and those coming on duty in hospitals.
The coroner had also recommended that a dedicated time should be set aside at the end of each shift for this to happen.
He recommended that each hospital in the Irish state has a protocol for sepsis management; that modified early warning score charts are introduced in all hospitals as soon as possible; and that there is effective communication between patients and relatives to ensure they are fully aware of treatment plans.
The other two recommendations are that medical and nursing notes are kept separately and that no additions are made to notes, where the death of a person will be subject to an inquest.
Dr MacLoughlin passed on his sympathies to the widower of Mrs Halappanavar, Praveen Halappanavar.
The coroner said Mr Halappanavar had shown tremendous loyalty and love to his wife during her final days.
Speaking after the verdict, Praveen Halappanavar said he still had no clarity as to why his wife had died.
He told reporters that he owed it to his wife and her family to pursue the truth of what had happened.
Mr Halappanavar described the treatment his wife received in the days after she was admitted to hospital as "horrendous" and said somebody had to take ownership for that.
Speaking outside the Galway County Council buildings, he said his wife had not benefited by going to the hospital until after 24 October, when she was moved to intensive care.
He said he felt doctors could have intervened as soon as they knew the pregnancy was not viable.
Mr Halappanavar said he would now "sit back and consider the next step".
He thanked the Irish police, the coroner and the jury as well as his friends for the support they had given him.
Earlier, he said today was a poignant one as it was his wedding anniversary.
The conclusion of the inquest comes on the same day that the couple would have been celebrating their fifth wedding anniversary.
Following the inquest, Mr Halappanavar said there were still some questions that he wanted answered and that he still had no clarity as to why his wife had died.
The chief operating officer at the Galway Roscommon Hospital Group acknowledged there were lapses in the standards of care provided to Mrs Halappanavar.
Tony Canavan said that all the recommendations made by the coroner would be taken on board.
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