Hospital failed to provide ‘most basic elements of patient care’, says watchdog
Staff failed to recognise and act upon signs of clinical deterioration in a timely manner
Marty Whelan, Health Information and Quality Authority head of communications, chief executive Dr Tracey Cooper, consultant anaesthetist Dr Nuala Lucas, and director of regulations Phelim Quinn at the publication yesterday of the report into the death of Savita Halappanavar. Photograph: Brenda Fitzsimons
University Hospital Galway failed to provide Savita Halappanavar with “the most basic elements of patient care” and failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner, according to a report by the State’s health watchdog.
The report by the Health Information and Quality Authority into Ms Halappanavar’s death last year points to 13 “missed opportunities” which, had they been identified and acted upon by the hospital, “may potentially have resulted in a different outcome for her”.
Among the missed opportunities listed in the report are a failure to carry out the recommended four-hourly observations of her temperature, heart rate and blood pressure and a failure to follow up blood tests.
“The consultant, NCHDs and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time,” according to the report. “However, this did not happen.”
It says the most senior clinical decision maker involved in the provision of care to Ms Halappanavar at any given time should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly. “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”
It says the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Ms Halappanavar did not appear to act in a timely way in response to her clinical deterioration and the report is critical of a failure to act or escalate concerns to “an appropriately qualified clinician”.
Ms Halappanavar, who was 17 weeks pregnant, died in the hospital of sepsis last October 28th following a miscarriage.
The 257-page report from Hiqa is the third report into the death of Ms Halappanavar, and follows a coroner’s inquest and an inquiry by the HSE.
In addition, the report says the clinical governance arrangements within the hospital failed to recognise that vital hospital policies were not in use, nor were arrangements in place to ensure the provision of basic patient care on St Monica’s Ward, the gynaecology ward in which Ms Halappanavar was accommodated.
The report points out that the Galway hospital developed a local Modified Obstetric Early Warning Score chart in 2009 but this was not in use on the ward three years later, in October 2012.
No formal protocol
It says there was no formal clinical escalation protocol and no emergency response team in place at the hospital and while sepsis guidelines were in place, clinical governance arrangements were “not robust enough” to ensure they were adhered to.