Second Opinion: Reports fail to say why bad things happen
Praveen Halappanavar says he still does not know why his wife, Savita, died. Photograph: Brenda Fitzsimons
Last week I had a eureka moment: “why”really is the most important question of all. I was listening to Praveen Halappanavar explaining to Miriam O’Callaghan on RTÉ Radio 1 that he still does not know why his wife, Savita, died and he will pursue his inquiries until he gets “to the bottom of the truth”.
He is quite right. The inquest findings and the HSE report into her death describe in great detail what happened. Why they happened is a mystery.
About a hundred years ago, Rudyard Kipling (1865-1936), the English short-story writer, poet and novelist, wrote the Just So stories, which try to explain why things are the way they are and why things happen the way they do.
In The Elephant’s Child, Kipling wrote “I keep six honest serving men (They taught me all I knew); Their names are What and Why and When, and How and Where and Who.”
These questions are the basic inquiry tools used by most report writers. The hardest question to answer is why, which, if rigorously pursued, can expose deep-rooted causes and effects: why did that happen and why does it keep on happening?
Unfortunately, the “why” question is hardly ever answered to any great extent when investigations are carried out within the Irish healthcare sector.
Cut and pasted
Even though the services are completely different, some of the findings of the Kilkenny incest case 20 years ago, the HSE report into the death of Savita Halappanavar, and the recent HSE review of the management of cases of neglect, could have been cut and pasted from one to the other.
Record keeping is one example. The Kilkenny Incest Investigation recommended that records must be accurate, comprehensive, dated, signed, legible and available.
The recently published Review of Practice and Audit of the Management of Cases of Neglect: Report on the Findings of the Pilot Phase of the National Audit of Neglect found that the language used in the records did not “convey the full horror of children’s living circumstances. Words such as ‘dirty’ and ‘unhygienic’ do not adequately describe the situation endured by some children in homes where beds were saturated with urine.”
The HSE report into Savita’s death found a consistently poor quality of documentation within the obstetrics and gynaecology records: illegible staff signatures, entries undated and incomplete.
Why is keeping records such an ongoing problem for those working in the healthcare sector?
There is a level of ignorance among health professionals in general about best practice and when interventions must happen. The review into neglect found that in many cases the child’s circumstances did not improve despite the involvement of statutory services.
The threshold for escalating neglect cases to the Child Protection Notification System (CPNS) differed considerably in the three HSE areas and was often too high. “This appeared to be due in part to a lack of understanding of the harsh reality of everyday life for children [and] the cumulative consequences of neglect”.
In Savita’s case there was a “lack of recognition of the gravity of the situation and of the increasing risk to the mother”. Ineffective passive approaches seem to be the preferred option taken by HSE staff.
Review of neglect
The review into neglect found that parental resistance to change and non-compliance with child-protection plans was not adequately challenged. Savita’s care plan was to “await events”.
The HSE report into her death notes passive approaches, while delays in aggressive treatment appear to have been “either due to the way the law is interpreted . . . or a lack of appreciation of increasing risk to the mother”. Why?
The Kilkenny Incest Investigation recommended that the roles and responsibilities of all staff should be outlined.
Twenty years later professionals are still unsure about their role and authority in children’s services, just as they were in the management of Savita’s care.
The Kilkenny Incest Investigation found that each health discipline dealt with the case “entirely separately and without interdisciplinary communication and co-operation”.
The review into neglect found “gaps in interdisciplinary working” and “communication challenges across disciplines”. In Savita’s case, there was “a lack of clear guidelines for the communication of information”. Why is communication between disciplines still a problem?
There we have it. Every report about healthcare carried out in the past 40 years highlights the same problems: record keeping, ignorance about best practice, passive approaches and poor communication between disciplines.
Why have these problems not been fixed? It’s a good question.