An investigation into the death Savita Halappanavar lays bare unacceptable practices, Health Minister James Reilly has said today.
The Government has asked regulatory bodies the Medical Council and the Nursing and Midwifery Board to advise on what actions need to be taken as a result of the inquiry's findings.
Minister Reilly said he was also calling in the Institute of Obstetrics and Gynaecology to help him develop a response to "serious concerns" raised by the investigation into Ms Halappanavar's death.
"It is a hard-hitting report which spares nobody and doesn't pull any punches," he said.
"It lays bare a set of unacceptable factors that led to the tragic death of a young woman.
"We must study this report in great detail, learn the relevant lessons and consider how best to implement its recommendations."
Minister Reilly said the report would be intensely scrutinised by his department, while he awaited the outcome of two separate probes into the death at Galway University Hospital last October.
Both the Health Information Quality Authority and a coroner are carrying out independent investigations.
Minister Reilly said the clinical inquiry, headed up by Sabaratnam Arulkumaran for the Health Service Executive (HSE), identified key causal factors and contributory factors that led to the tragedy.
In particular, it exposed inadequate assessment and monitoring of the Indian dentist, a failure to offer her all options as she faced an inevitable miscarriage as well as non-adherence to clinical guidelines, he said.
Mr Reilly said Ms Halapannaver's widower Praveen and her family have had to endure a terrible loss that should never have occurred.
"We must all work together to ensure that the lessons are learned and implemented to prevent such a tragedy occurring again," he added.