Boylan evidence brings further clarity to events in death of Savita Halappanavar

Dr Peter Boylan, the second expert witness to give evidence to the inquest into the death of Savita Halappanavar, brought further clarity to the events leading to her death last October at University Hospital Galway.

A consultant obstetrician and gynaecologist and former master at the National Maternity Hospital (NMH), Dublin, Dr Boylan initially provided background information on sepsis in pregnancy.

In a recent major report, infection in the genital tract became the leading cause of direct maternal death in the UK for the first time since the confidential inquiries into maternal deaths commenced in 1952. Despite this, he said the mortality rate from maternal sepsis remains low, at about one per 100,000 maternities. Similar figures apply in the Republic; in the past 25 years during which more than 210,000 women gave birth in the NMH, there were two deaths from sepsis.

Significantly, the UK report referred to by Dr Boylan, who is clinical director at the NMH, warns that progression from sepsis to severe sepsis to septic shock can be rapid. For many healthcare workers, it notes, this means “the fulminating nature of many of the cases is surprising and shocking when it does happen.”

In his analysis of Ms Halappanavar’s case, the expert witness noted that on Tuesday, October 23rd, the patient was stable and her life was not at risk. “Termination of pregnancy was therefore not a practical, legal proposition on the 23rd,” he said.

Deteriorated
Her condition deteriorated overnight and in his opinion, she developed clinical signs of chorioamnionitis (infection of the foetal membranes) early on Wednesday. By the time of her consultant's ward round at about 8.25am on October 24th, there was "a developing real and substantial risk" to Ms Halappanavar's life.

Dr Boylan was notably critical of the patient’s care on the Wednesday morning. Her blood pressure dropped progressively from 7.50am when the reading was 100/75 to 10.30am when it was 84/50 to 13.00 hours when it had dropped to 73/38. He questioned why no doctor was informed of the pressure deterioration during this five-hour period. He was also critical of the quality of the clinical notes that morning.

'Poor-quality' notes
"The notes on the morning of October 24th, following the ward round, are of poor quality, retrospective and not really helpful in understanding the sequence of events." he said.

Dr Boylan was forthright about how unhelpful the law on abortion is when an obstetrician is dealing with a case such as Savita’s. He referred to a legal vacuum that hampers a consultant’s professional practice. It is clearly his view that without the legal and ethical constraints that doctors must work under, Ms Halappanavar could have been offered a termination on either the Monday or Tuesday of her admission and that this could have saved her life.

In addition, he was of the view that from 9.30am on Wednesday, a termination would not have affected the eventual outcome, primarily because Ms Halappanavar became critically ill in such a short space of time.

Now that we have heard from two key expert witnesses, what conclusions are emerging from this inquest?

There were deficiencies in Ms Halappanavar’s clinical care, according to both Dr Boylan and Dr Susan Knowles, consultant microbiologist. These included a failure to take and record the patient’s vital signs consistently, poor note-keeping and a delay in alerting medical staff to a precipitous fall in her blood pressure on the Wednesday.