more than two years ago.

Dr Coulter Smith blamed inaction in relation to these and previous reports on maternity services for significant under-resourcing in the area.

“Despite representations to the HSE and to the Department of Health, little has been done in relation to making any progress in improving infrastructure, services or staffing levels in the maternity sector,” he said, writing in the clinical report for 2013.

Staff

The Saolta hospital group, which includes University Hospital Galway where Ms Halappanavar died, is due to publish a progress report on implementing recommendations made on foot of her death.

There were three maternal deaths in the hospital in 2013, compared to two in 2012 and three in 2011. The deaths of a 37-year-old and a 34-year-old were attributed to pulmonary embolism while a coroner’s report is awaited in the case of a 39-year-old woman who died after collapsing in another hospital following a “silent miscarriage”.

Deliveries

Dr Coulter Smith said it was unacceptable that the hospital had to transfer 10 of its sickest patients by ambulance to the high dependency unit of the Mater hospital. This was because it was not co-located with an adult hospital and didn’t have immediate access to intensive care facilities.