The Independent Review Panel report outlined the chronology of events on the morning of the tragedy. It detailed what happened from the time Ms Denise Livingstone arrived at Monaghan Hospital and left by ambulance for Cavan Hospital.
The report notes that Denise woke from her sleep with crampy abdominal pain at around 3.30 a.m. on December 11th.
She arrived at Monaghan General Hospital at 5.15 a.m. and was admitted by the night porter.
One of two staff nurses on duty called the surgical Senior House Officer while the other nurse took Denise's "vital signs".
The surgical Senior House Officer also noted Denise's vital signs. She complained of feeling a "gush of fliud" vaginally at this time.
The surgical SHO asked the staff nurse to transfer Denise to Cavan Hosital and he contacted the gynaecologist Senior House Officer at Cavan.
A limited history was given over the phone including the fact that Denise was 24 weeks pregnant and was bleeding.
The ambulance base was contacted at 5.20 a.m. The base was told that no midwife was available to travel with Denise to Cavan.
Denise was given 50 mgs of pethidine. At this stage she was getting pains every three minutes and she felt the baby was delivering.
At 5.28 a.m. the ambulance arrived at the treatment room with two emergency medical technicians. Both seemed aware delivery was imminent. Denise was given a second injection of pethidine at 5.35 a.m. At 5.39 a.m. the ambulacne left Monaghan General Hospital with Dneise, her sister Tina and the two technicians. No midwife went with them.