The HSE's long-awaited report of its probe into the Savita Halappanavar tragedy at University Hospital Galway (UHG) has finally been unveiled.
Its findings, while largely confirming what we have already heard through 'leaks' and the Coroner's inquiry, still make for grim reading and will occasionally shock even hardened observers of what have by now become frequent health service scandals.
You can read the details of this tale of sins of omission, commission, lack of coordination and dysfunction and ultimately, an untimely death at University Hospital Galway (UHG) here, and elsewhere.
The Savita report is a damning indictment of how not to run a health service.
Many of us will take assurances that our health service usually works well (and to be fair it usually does in spite of everything) at face value.
Then either ourselves or a loved one has to experience that system and we sometimes discover that due to a number of systemic and resourcing failures, when it is bad it can be horrific. Reading the Arulkumaran report, many people will identify with how hope can turn to horror in our hospital system.
You might know the feeling you get from time to time if you have to experience an Irish hospital. Staff are working hard, but you feel that very little seems to be getting done, and that someone somewhere might be missing something vital. You start to get worried.
In the meantime you wait, and wait and wait to see a doctor or a nurse simply to find out what's going on. You know there's something not quite right with how things are being run but you can't quite put your finger on it, and may be too sick or tired to protest.
Our health system is generally regarded as pretty efficient by world standards. And there is always a great sense of satisfaction and relief in knowing you or a family member has been treated efficiently and safely when they were at their most vulnerable. Yet this does not always happen in Irish hospitals.
Their systemic defects can sometimes kill or harm people unnecessarily.
Now this admittedly can happen even in the best health systems. However, while attending scandal investigation press conferences, you cannot help but wonder if our health service ever learns from its mistakes or whether it properly implements systems to maximise safety and quality.
That a previously healthy young woman in the early stages of pregnancy had her impending joy turned to horror by serious deficits in a hospital service, and due to the fallout from a cowardly political and societal system, is surely one of the great scandals to date in 21st century Ireland.
Gaps in the assessment of Savita and the 'chilling effect' of a lack of legal termination guidelines for doctors proved to be a lethal combination for a young woman who trusted our health service to look after her properly.
On the termination issue, one excerpt from the report typifies the potential difficulties for doctors and the Russian Roulette involved for patients. It also puts what many feel are scaremongering and misogynistic statements from our Catholic bishops into a real-time context:
"Consultant 1 recalled at interview (with the Halappanavars) that on the 23rd of October the patient and the patient's husband enquired about the possibility of using medication to induce labour as they indicated that they did not want a protracted waiting time when the outcome was going to be an inevitable miscarriage. The consultant stated at interview that (s)he advised the patient and her husband that this was not possible under Irish law. At interview, the consultant indicated that the law is such that:
'If there is a threat to the mothers' life you can terminate. If there is a potential major hazard to the mothers' life the law is not clear.... There are no guidelines for inevitable miscarriages,' she said.
There is difficulty in interpretation of law in relation to ‘what constitutes a potential major hazard or threat to mother's life'. This needs clarification. The consultant clearly thought that the risk to the mother had not crossed the point where termination was allowable in Irish law on the morning ward round on the 24th."
The medical team clearly felt that earlier on in her hospital stay the threat was to the Savita's health and not her life, therefore a termination was not possible.
However, the inquiry Chairman has stressed that the type of infection Savita had can progress very rapidly to an obvious threat to her life. The legal difficulties doctors felt they faced in the Savita case meant that by the time a termination was deemed permissible three days after Savita's admission, under her medical team's interpretation of the law, it was too late to save her.
Certainly there may is an issue here of where does a threat to a woman's health end and a threat to a woman's life begin- it's not an exact science.
A key factor here too was that a miscarriage in Savita's case was practically inevitable and did eventually take place.
Another medical team in the same hospital, or doctors in another hospital, perhaps may have had a different interpretation of the legal position, and might have intervened earlier, but that is open to speculation.
All we can be sure of is that legal clarity and clearer professional guidelines based on any new law is needed here, and it can only be hoped that the Government's efforts in this regard will bear fruit.
However, leaving aside the termination issue (admittedly not easy to do) the fact remains that severe deficiencies in assessment and monitoring of a severely ill patient played a major role in her unnecessary death.
The word 'tragedy' is often used in the Savita Halappanavar cases She is sometimes referred to in the media as "tragic Savita'.
This implies that her terrible death was just one of those unfortunate things that happens from time to time. That it couldn't really be helped, nothing more could be done. And isn't it awful.
This is patronising and an insult to her memory.
It also lets those who should be ensuring that our service is as safe as possible off the hook to a certain extent.
The people at the top seem to be doing their best, but you have to question whether it is always enough.
Because, as each succeeding scandal unfolds, you keep hearing the same assurances at press conference after press conference.
Let's be clear about this, the Savita Halappanavar case can't be defined as simply a tragedy, it's a scandal, no more no less; perhaps the worst in a series of healthhcare scandals that have bedevilled the health system over the past decade.
'Scandalous' is defined as causing general public outrage by a perceived offence against morality or law. The Oxford Dictionary is right on all counts there.
It's a scandal that requires, as a response, a little bit more than the usual health service assurances involving:
*Official apologies/sympathy. Yes, they have to be trotted out but they're essentially valueless unless something is done to right the wrong that has taken place.
* These events are very rare' and 'we are working to improve things through implementing new guidelines in the latest investigation report.' A distinct air of deja vu wafts in at this point. And in any case UHG already had guidelines for sepsis management which staff did not adhere to in the Halappanavar case.
* 'It's all about learning, and promoting future safety not about apportioning blame' (really?)
* 'No individuals are mentioned (or held accountable) in the report' Why not? Oh, I get it. Sorry, your Honour.
* 'These things happen in other countries too.' Not much comfort here for the Halappanavar family and others.
When scandal strikes, to put it at its most crude, the default position seems to be 'we failed again but we'll try to do better next time.'
And this is not to accuse most individuals running or working in the health service of being inherently callous, unfeeling or simply incompetent- usually, it's quite the contrary.
Admittedly, official statements at a time of crisis are meant well, and certainly implementing new guidelines to improve quality of care and safety are welcome.
But in explaining how a scandal happened there is a tendency among those running the system to fall into a type of 'groupspeak' that, while well-intentioned, fails to fully deal with the enormity of what has occurred.
What is never really stated openly at times like this is if people were doing their jobs properly or being told to do their jobs properly by those in charge, these scandals wouldn't happen as often and we wouldn't need yet another set of safety rules.
In this context, perhaps the most welcome statement made yesterday was by Health Minister James Reilly.
He said his Department was referring the Savita report to the medical and nursing regulatory bodies.
Minister Reilly said his Department was forwarding the Savita report to both professional bodies 'for their early consideration and advice on any action considered appropriate, as the report raises several important issues in relation to professional practice.'
The HSE, when pressed on whether regulatory or disciplinary action might be taken, kicked the matter to touch, stressing that the Savita report was primarily a safety, rather than a blame-apportioning report.
In this case, the Minister's actions are not mere grandstanding. Dr Reilly, to give him credit on this occasion, appears to have the novel notion that some people should, where necessary, be held accountable for their actions, subject to due process.
It remains to be seen, however, whether health service management will be part of any accountability scenario in the Savita case.
It is certainly good to hear that efforts are being made to promote quality and safety in our health service.
However, at some stage of this long drawn out process of self-reflection, someone somewhere surely has to be held accountable when things go seriously wrong.
Otherwise, surely the health service will never learn from its many mistakes.
Sometimes, saying sorry just isn't enough.
Nursing board seeks Savita staff rosters
Discussions on this topic are now closed.