The HSE's probe into the death of Savita Halappanavar has found that her request for a termination should have been considered a number of days before she died following a miscarriage.
However, staff reportedly indicated that they could not carry out a termination as their 'hands were tied' legally on the matter, a draft version of the report of the inquiry has shown.
The draft HSE report, seen by the Evening Herald, has said the serious infection which led to Savita's death was not diagnosed for three days.
Savita Halappanavar was 17 weeks pregnant and was miscarrying when she attended University Hospital Galway on 21 October - she died a week later from a serious infection. Details of her case emerged in the media the following month.
The report is still being finalised and its contents are being shown for clarifications and comments to those involved in Savita's care who were interviewed as part of the inquiry's deliberations. The final version is expected to be published at the end of the month.
However, indications are the final report is likely to substantially confirm Praveen Halappanavar's account of the circumstances leading to his wife's death, including the reason why a termination was refused.
The draft report also points to serious procedural and resource deficits relating to how Savita was treated at University Hospital Galway.
For example, the report says tests showing possible blood infection taken on the day Savita was admitted were never followed up by hospital staff. It says there was a lack of clarity among key staff on who was responsible for acting on the blood test results.
Different staff members told the probe it was not their responsibility to follow up the test results.
The report also says there was no record of pulse, blood pressure or temperature or the ordering of any further tests at an early stage to check for the possibility of blood infection.
It also indicates that some staff did not have sufficient knowledge of rapid techniques to make a diagnosis of sepsis/blood poisoning.
The draft report also indicates that staff at the hospital were often under too much work pressure to deal immediately with Savita, whose condition was rapidly deteriorating.
The report says in order to prevent the spread of infection, staff should have considered performing an abortion, even before the couple had requested one. It says the lack of clear legal guidelines on the issue of termination was a contributory factor in the tragedy.
The report also indicates that the reason given by medical staff for not performing a termination was the legal restrictions with this issue when a mother's life is thought to be in danger.
Staff are reported to have told Savita and Praveen Halappanavar of their interpretation of the current legal situation on abortion, which 'tied their hands' as regards a termination.
According to the document leaked to the Herald, a consultant told the inquiry team that following the couple's request for medication to speed up the miscarriage process, they were advised of the Irish legal position in relation to requests for terminations in such situations.
The consultant said under Irish law, if there was no evidence of risk to the life of the mother 'our hands are tied', so long as there is a fetal heartbeat. However, there appears to be no mention of the previously reported phrase about Ireland being 'a Catholic country.'
The report says, however, there was an over-emphasis on the need not to intervene until the fetal heart had stopped beating, together with an under-emphasis on the need to focus attention on the monitoring and managing of Savita for the risk of infection.
It also says that even before the Halappanavars asked for a termination, the clinical situaiton indicated that there was a significant and increasing risk to the mother and performing an abortion should have been considered whether or not it was requested by the patient.
The report's findings on the termination issue will be seen in many quarters as vindicating the Government's decision to clarify this matter through new legislation and guidelines.
The findings, however, will also pose serious questions for the hospital and the HSE on how maternity care is provided and resourced.
The draft report also indicates that better guidelines are needed in dealing with serious infection in pregnancy.
The Halpappanavar family decided not to cooperate with the HSE probe.
The inquiry was led by a UK expert, Prof Sabaratnam Arulkumaran.
The HSE came in for considerable criticism on how it handled the case in the weeks following Savita's death. It was forced to replace three members of its initially-appointed inquiry team who worked in University Hospital Galway.
Health Minister James Reilly said today the HSE inquiry team was still compiling its findings and he hoped to receive the final report of the HSE's clinical review within ten days.
Dr Reilly said he could not comment on the leaked draft report and would await the publication of the final version of the report.
Fianna Fáil Health Spokesperson Billy Kelleher called on the Minister to immediately publish the report.
"In light of the report being leaked it is essential that Minister Reilly move to publish the full report as a matter of urgency. We cannot have a situation where an issue as sensitive and serious as this is being reported on in the media, based on a partial leaking of the document, and the family concerned and the public do not have access to the full facts," Mr Kelleher said.
Meanwhile, the solicitor for Praveen Halappanavar, Gerard O'Donnell, said it was very disappointing that a draft of the report had been leaked to the media before Mr Halappanavar had been briefed on the outcome of the inquiry.
He said his clients was very upset at the leaking of the report.
Minister for Communications Pat Rabbitte said the lack of clear guidelines on abortion may have tied the hands of doctors dealing with the case of Savita Halappanavar.
The health safety body HIQA is carrying out a separate inquiry into the circumstances surrounding Savita's death. This is not expected to be completed for a number of months.
In the meantime, the coroner's inquiry into the case is due to resume in early April.
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