Lessons from the Savita inquest

  • Niall Hunter, Editor

Over the past week we have seen probably the most extensive coroner's probe of a serious clinical incident ever held in Ireland, and it is likely to continue for a number of days yet.

The scenes from the final days of Savita Halappanavar's short life reinacted through testimony at a Galway coroner's inquiry are grim and distressing, not least for her husband Praveen, but for the whole country and the outside watching world.

However, this detailed examination of the circumstances surrounding Savita's death may ultimately give us something positive.

It would be unfair for the findings of the Savita coroners' inquiry to be used to cast aspersions on the safety of our maternity service as whole; however, what is currently being revealed at the inquest in Galway will ultimately help give us a maternity service that will have proper safeguards in place to deal with women who are seriously ill.

Judging from the Savita case, these safeguards appear to be seriously lacking.

The inquest proceedings may aid the Government in trying to provide some clarity to the issue of terminating a pregnancy when there is a substantial threat to the life of the mother, certainly in terms of further defining the degree of risk to the life of the mother in order to allow a termination, although this was never going to be an easy legal task.

Making maternity care safer for Irish women will be helped too by the yet to be published HSE inquiry report into Savita's death, the HIQA investigation into the incident, and any further legal or regulatory proceedings that might result from the events at University Hospital Galway between last October 21 and 28.

One thing is certain from the evidence so far - Savita Halappanavar was not treated in an environment where the procedures and structures ensured that patient safety was being upheld at all times.

While there are still unanswered questions about the the tragic death of Savita from sepsis following a miscarriage , the coroner's inquest has so far pointed to a key theme in previous major medical scandals - serious system failures, including, it would appear, human error and the lack of safeguards to minimise these errors and omissions.

The key issues that have emerged to date are why hospital staff took so long to act on the early warning signs that Savita's condition was serious and deteriorating fast, and, of course how significant was, and the circumstances surrounding, the refusal of a termination at an early stage following Ms Halappanavar's admission on Sunday October 21 2012.

What we have heard about so far at the inquest has a familiar ring, and has been a theme of previous healthcare scandals in recent years in terms of how care is provided in these circumstances.

These include - defects in the organisation of tests and treatment plans bordering on chaos, punctured by poor communication, basic mistakes in some aspects of diagnosis and treatment, and lack of coordination and oversight. 

The inquest has been told, among other things, that the patient was initially sent home with back pain before being readmitted, there were key delays in blood tests (referred to during the inquest by Savita's treating consultant), and pulse rate, blood pressure and other vital signs were not checked sufficiently at key periods in Savita's care.

The inquest has heard doubts about the strength of the antibiotics used on Savita and delays in crucial information about a foul-smelling vaginal discharge, indicative of serious infection, being passed on and acted on.

At vital stages of Savita's treatment, important information does not appear to be have been conveyed sufficiently quickly in order to treat her more effectively.

The termination issue, has, as expected, loomed large in the proceedings, and is likely to be debated further as more expert witnesses are called when the inquest reopens on Wednesday.

Savita's consultant, Dr Katherine Astbury, said she decided she could not allow for a termination early in in her hospital stay as there was still a fetal heartbeat and at that stage on the balance of probabilities there did not appear to be a serious risk to the life of the mother, which would have allowed for a termination in the circumstances.

The consultant's evidence therefore claimed that her room for manoeuvre until lunchtime on the Wednesday was limited by the current state of Irish law surrounding abortion.

The consultant denied using the oft-quoted and controversial phrase 'this is a Catholic country' but said she had told Savita after she had asked for a termination on the Tuesday morning "In this country, it is not legal to terminate a pregnancy on grounds of poor prognosis for the foetus."

The consultant said Savita has asked her about her termination once, but Praveen Halappanavar says his wife asked for a termination three times over a period of two days and was told by the consultant this couldn't be done because Ireland was a Catholic country.

During the inquest, a midwife, Ann Maria Burke, admitted telling Savita that this was a Catholic country but stressed that she did not mention this in a hurtful context.

Dr Astbury said after Savita's condition had deteriorated she decided a termination was necessary around lunchtime on the Wednesday. She said if she had known earlier about a foul-smelling discharge discovered in early morning by one of her junior doctors, indicating serious infection, she would have carried out a termination sooner.

She agreed there had been system failures.

In the event, a scan showed the fetal heartbeat had stopped and Savita spontaneously delivered a dead baby girl later that afternoon. Her condition continued to deteriorate and she died on Sunday October 28.

It is still not clear whether a termination at an earlier stage would have made a major difference to the tragic outcome for Savita Halappanavar, although this probably be the subject of further examination at the inquest and beyond.

The inquest is expected to resume on Wednesday and is expected to last for a further three days. The appropriateness or otherwise of the interpretation of the current legal position on abortion in relation to Savita's treatment is likely to feature prominently in the resumed proceedings.

The HSE report into the Savita case is expected to be published after the inquest ends, following consultation with Mr Halappanavar. The HSE report does not name individual staff, but will essentially echo many of the points raised during the inquiry about shortfalls in the care of Savita

A separate, independent inquiry into the issue by the health safety body HIQA, is not expected to be completed until late into the summer.

It should be noted that the terms of reference for the HIQA inquiry include: "(to) review the safety, quality and standards of services provided by the HSE at UHG to patients, including pregnant women, at risk of clinical deterioration and as reflected in the care and treatment provided to Savita Halappanavar. This will include the diagnosis and management of patients with sepsis. Assessment of the services will be made against the National Standards for Safer Better Healthcare and relevant national and international evidence of what is known to achieve best outcomes."

HIQA is also reviewing review the safety, quality and standards of services provided by the HSE at UHG to patients, including pregnant women, at risk of clinical deterioration and as reflected in the care and treatment provided to Savita Halappanavar. "This will include the diagnosis and management of patients with sepsis,"HIQA says.

The HIQA review is expected to include recommendations for hospitals nationally on the management of seriously deteriorating maternity patients.

In the meantime, the HSE has yet to introduce its planned national early warning system designed to deal more effectively and quickly with rapidly deteriorating maternity patients.

In view of the gaps in some basic hospital procedures that have emerged to date in the Savita inquest, such a system is long overdue.

Maternity early warning system not in place

'Termination could have saved Savita's life'



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