Report identifies multiple failures in treatment of Savita Halappanavar
HSE says clinical staff at Galway University Hospital failed to properly assess or monitor dying woman’s condition
Inquiry chairman Sir Sabaratnam Arulkumaran (left) at the publication of the Health Service Executive clinical review report into the death of Savita Halappanavar today. Photograph: Eric Luke/The Irish Times
Journalists read the Health Service Executive clinical review report into the death of Savita Halappanavar in Dublin, today. Photograph: Eric Luke/The Irish Times
Key factors in the death of Savita Halappanavar included multiple failures by clinical staff to properly assess or monitor her condition, according to a Health Service Executive review group report published today.
Mrs Halappanavar died of septicaemia in her 17th week of pregnancy at Galway University Hospital last October.
The circumstances of her death resulted in public outcry over the State’s abortion laws.
Full text of HSE review into death of Savita Halappanavar
The report, described by Minister for Health James Reilly as a “hard-hitting report which spares nobody and doesn’t pull any punches”, identifies three main factors which led to Ms Halappanavar’s death.
- A failure to adhere to clinical guidelines for prompt and effective management of sepsis when it was diagnosed
- Not offering all management options to the patient as she experienced inevitable miscarriage, even though the risk she faced increased from the time her membranes ruptured
- Inadequate assessment and monitoring that would have allowed the clinical team to recognise and respond to the signs that her condition was deteriorating.
The report, which does not mention any names, also makes significant recommendations aimed at improving legal clarity and medical handling of complicated obstetric emergencies, including sepsis which led to Mrs Halappanavar’s death.
It found an apparent over-emphasis on the need not to intervene until the foetal heartbeat stopped and not enough emphasis on the need to focus on monitoring and managing the risk of infection. “The interpretation of the law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard,” the report added.
The report also sheds some new light on additional failures in the handling of Mrs Halappanavar’s condition. For example, on the day she was admitted to hospital the report states that no ultrasound was carried out by a specialist registrar because a probe used for scanning was broken.
Among the report’s main recommendations are:
- The Oireachtas should urgently consider amending the law - including any necessary Constitutional change - to help provide clinicians with a clear legal context for the management of “inevitable miscarriage”
- The HSE should develop and implement national guidelines on infection and pregnancy, along with education programmes to improve the quality of care in pregnancies complicated by infection
- Clear and precise national clinical guidelines to meaningfully assist clinical professionals who have to use their professional judgement in cases which may involve a rapid deterioration or emergency
The report was finalised by an inquiry team chaired by UK obstetrician Prof Sabaratnam Arulkumaran.