Savita report: Hospital staff failed to offer all options

The clinical inquiry into the death of the 31-year-old dentist found the most likely cause of her inevitable miscarriage was infection, with the risk of that infection and sepsis increasing after her waters broke.

Mrs Halappanavar died on October 28 at Galway University Hospital, a week after being admitted.

She suffered multiple organ failure from septic shock four days after she miscarried a dead foetus.

Her widower Praveen, who is out of the country, has maintained that she repeatedly requested a termination but was refused because a foetal heartbeat was present.

[comment] Praveen Halappanavar[/comment]

The Government moved to introduce legislation for limited abortion, as required by a 1992 ruling in the Dublin Supreme Court, on the back of a public outcry over Mrs Halappanavar’s death.

World-renowned professor of obstetrics and gynaecology Sabaratnam Arulkumaran headed the review on behalf of the Health Service Executive (HSE).

[comment] Sabaratnam Arulkumaran[/comment]

Dr Arulkumaran said the Halappanavars had inquired about the possibility of having a termination but that this was not offered or considered possible by the clinical team until the afternoon of Wednesday October 24 because of legal constraints.

Medics in Ireland had to be sure there is a real and substantial risk to the woman’s life in order to grant a termination.

The chairman said the plan was to “await events”, which he said is appropriate provided it is not a risk to the mother or foetus.

“Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have led to reconsideration of the need to expedite delivery,” he said.

“Monitoring and adherence to guidelines for the prompt and effective management of sepsis would likely have helped to prevent rapid deterioration of the patient.

“Delaying adequate treatment including expediting delivery in a clinical situation where there is prolonged rupture of the membranes and increasing risk to the mother can, on occasion, be fatal.”

Mrs Halappanavar’s waters broke in the early hours of Monday morning and her condition deteriorated in the early hours of Wednesday morning.

The long-awaited report was published two months after an inquest jury ruled unanimously that Mrs Halappanavar’s death was by medical misadventure.

The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar’s care before she died, but coroner Ciaran MacLoughlin said they did not contribute to her death.

[comment]Ciaran MacLoughlin[/comment]

The review found concern over the law on when an abortion or forced delivery could have been allowed.

The review team found that, by the Wednesday morning during ward rounds, a diagnosis of sepsis secondary to chorioamnionitis had been made.

They said this would have merited expediting delivery to reduce the risk of infection to the mother.

“The gravity of the situation was increasing but appears not to have been recognised and acted upon,” it said.

“This was a complex clinical situation and a request for advice/support from a consultant and other specialities would have been beneficial.

“The investigation team considers that the situation was complicated by the difficult association with the application of the law in Ireland relating to the termination of a pregnancy.

“The investigation team is satisfied that concern about the law, whether clear or not, impacted on the exercise of clinical professional judgment.”

It was several hours before the decision to terminate the pregnancy was taken.

No-one was named in the report.

It found an apparent over-emphasis on the need not to intervene until the foetal heartbeat stopped and not enough emphasis on the need to focus on monitoring and managing the risk of infection.

It noted that when Mrs Halappanavar's consultant, Dr Katherine Astbury, was finally called to review the patient at 1.10pm on the Wednesday, she went to collect a scanner on the way.

"The interpretation of the law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard," the report added.

It warned that similar incidents with a similar clinical context could happen again in the absence of clarity on the law and a lack of national clinical guidelines.

Dr Arulkumaran has recommended that clinicians, health and social care regulators and politicians consider the law and guidelines on the management of inevitable miscarriage early in pregnancies.

Overnight the Irish Government published proposed new abortion laws so medics can carry out terminations where there is a real and substantial risk to the life of a woman, including suicide.

Dr Arulkumaran said the consultant believed her hands were tied by Irish law, which he said was a significant factor in the death.

"If it was my case I would have terminated the pregnancy," he said, highlighting Mrs Halappanavar's high pulse rate and signs of infection.

Dr Arulkumaran would not commit to which day he would have terminated the pregnancy, and if her life would have been saved by an earlier termination as sepsis may have already set in.

He added that there had been a "cascade effect, domino effect" in system failures missing vital signs of infection in Mrs Halappanavar from the first day she was admitted, when a blood test which showed signs of infection was not followed up.

Other failures include not checking her vitals every four hours after her membranes ruptured and, by the Wednesday morning, awaiting more test results instead of fully appreciating the deteriorating and complex clinical situation missing the opportunity to intervene.

Mrs Halappanavar was rushed to a high dependency unit after delivering a dead baby daughter that afternoon and by that night was in intensive care, where she died on the Sunday.