Notes added to by internal investigation, midwife tells Savita Halappanavar inquest

Medic who first raised sepsis concerns says he was not told of elevated pulse

 Praveen Halappanavar arriving today at the inquest into the death of his wife Savita. Photograph: Eric Luke / The Irish Times

Praveen Halappanavar arriving today at the inquest into the death of his wife Savita. Photograph: Eric Luke / The Irish Times

Tue, Apr 9, 2013, 17:05

A midwife has told the Savita Halappanavar inquest her notes were added to afterwards by Galway University Hospital's internal investigation.

Miriam Dunleavy said marks on the notes were not written by her and she thought they were put in by internal investigation.

Lawyers for the hospital, responding to queries from coroner Ciaran McLoughlin, said they would check the exact situation.

Ms Dunleavy, who worked on the ward where Ms Halappanavar was treated last October, said she didn't contact a doctor after her membranes ruptured the day after admission. She said it wasn't an emergency but a natural progression of her condition and if she had called a doctor, she would have been told to keep an eye on the patient.

She said it was a very busy night with all 15 beds in the ward occupied. On the Tuesday night, she was told at handover that Ms Halappanavar's pulse was raised. She agreed this was something that should be addressed by a doctor.

Asked if she was aware of a misunderstanding between nursing and medical colleagues about the patient's pulse, Ms Dunleavy said she wasn't. It was a very busy night and four other patients were sick. Ms Halappanavar was one of the healthiest patients on the ward that night.

Ms Dunleavy said Ms Halappanavar rang the call bell at 4.15am on Wednesday October 24th because she and her husband were cold in their room and they needed blankets. Ms Halappanavar's teeth were chattering and she shivered as the blanket was pulled over her shoulder.

However, she made no complaint about pain and said she wanted to snuggle up and get back to sleep. She said she didn't recall checking the heater to see it was working, as Mr Halappanavar has claimed.

Asked if she had taken Ms Halappanavar's pulse, Ms Dunleavy said she hadn't. There was no evidence she was sweating at the time. "I decided not to do it," she told the inquest.

However, by 6.30am there were "dramatic changes" in her condition, she said. Her pulse was 160 beats per minute and her temperature had gone up to 39.6 degrees and there was a foul-smelling discharge from her vagina, senior house officer Dr Dr Ikechkwu Uzockwu noted.

Ms Dunleavy agreed with Eugene Gleeson SC, for Mr Halappanavar, that this indicated a life-threatening situation. She said it had occurred in the two hours previous to 6.30am.

"I've never seen a woman with an inevitable miscarriage get so sick so quick, and I've been seven years on the ward," she said. The deterioration was frightening. Mr Gleeson said a doctor should have been called earlier and claimed it would never be known what would have happened if Dr Uzockwu had been called the previous evening.

Earlier the senior doctor who treated Savita Halappanavar on the day she was admitted to Galway University Hospital has contradicted parts of the evidence given by her husband, Praveen.

Dr Andrew Gaolebale, a specialist registrar in obstetrics, informed Ms Halappanavar her pregnancy was no longer viable when he saw her last October 21st. She was 17 weeks pregnant but was diagnosed as miscarrying.

Dr Gaolebale told the inquest in Galway this morning that he was not informed of the results of a blood test on Ms Halappanavar and he was not told that her membrane had ruptured after he saw her, even though he was still on duty for another 12 hours.

Mr Halappanavar has said Dr Gaolebale told him his wife’s miscarriage would all be over in “a few hours” or in “four to five hours”.

However, Dr Gaolebale said he would never say that as it was not possible to predict how long it would take a patient with her symptoms to deliver the foetus. He felt it would happen within 24 hours.

Asked if he had told Ms Halappanavar there was “no going back” in relation to her pregnancy, as alleged by her husband, he replied: “That was not my phrase”.

Dr Olufoyeke Olatunbosun, a senior house office who first examined Ms Halappanavar on admission, said she presented at the hospital with lower back pain on October 21st. There was no vaginal bleeding, her abdomen was soft and there was tenderness in the pubic area.

She was diagnosed with back pain, given pain relief and sent home but came back two hours later complaining of a “dragging sensation”. Her membrane was found to be bulging and the registrar, Dr Gaolebale, was called.

Coroner Ciaran McLoughlin asked the witness what in retrospect Ms Halappanavar was sufferening when she was initially diagnosed with back pain.

Dr Olatunbosun said it was most likely miscarriage. She said she did not examine the patient vaginally because she was not showing any symptoms there. Neither did she carry out a test for leaking amniotic fluid, she told the coroner.

Dr McLoughlin questioned why a blood sample taken from Ms Halappanavar had not been followed through on. The witness said the test was done as a baseline in case did later suffer bleeding. Dr McLoughlin pointed out that “the baseline was not base, it was off the base” as it showed an elevated white blood cell count.

The inquest also heard from the first medic to raise concerns that Ms Halappanavar had spesis. Dr Ikechucwu Uzockwu, Senior House Officer at Galway University Hospital first raised concerns on sepsis, at about 7 am on Wednesday October 24th.

He told the inquest this afternoon he had been informed by a midwife Gallagher at 9 pm on Tuesday 23rd as Ms Halappanavar was complaining of weakness but that her vital signs were stable. “That’s what I was told.”

It was put to him that there was a statement from midwife Anne Maria Burke that Ms Halappanavar’s pulse was taken and found to be 110 beats per minute and that he had been told this.

“I was told the vital signs were stable,” he said. “I was not told of an elevated pulse. There is no question that if I had known she had an elevated pulse, this lady had ruptured membranes, I would have attended immediately.”

Eugene Gleeson, SC, for Mr Halappanavar said: “The membranes had ruptured 32 hours earlier. With the elevated pulse, isn’t that stingingly indicative of sepsis?” “Yes I would have been concerned but I was not told of the elevated pulse,” said the doctor. “You should have been told?” “I suppose I should have yes.”

He said he came to review Ms Halappanavar at about 6.30 am on Wednesday 24th. He said she had a tachycardia (an elevated heart-rate) of 160 beats per minute, a foul smelling discharge from the vagina, a temperature of 39.6 and her blood pressure was 100 over 60. He put her on antibiotics. He took both blood-samples and a vaginal swab. “You felt she had sepsis?” the coroner Mr Gleeson asked him. “I did.” “This would have been an emergency?” “Yes.”

He said earlier in evidence he had informed a more senior specialist registrar, Dr Sarah Campbell of his concerns and that she told him she would come to Ms Halappanavar to review her. “Did she?” asked Dr McLoughlin. “No,” said Dr Uzockwu.

“So she was the most senior person to realise early on that something was going on, at 6.30 on Wednesday morning,” said Dr McLoughlin. He told Dr Uzockwu he wanted Dr Campbell called to give evidence, “to see what she understood from your call”.

Dr McLoughlin asked him if he contacted the senior microbiologist in the hospital “as soon as possible”, as is mandated in the hospital’s guidelines on managing sepsis. He said he had not informed the microbiologist. The coroner also asked that three other additional witnesses be called and it is hoped two of these may be able to appear tomorrow.