Savita Halappanavar jury returns unanimous medical misadventure verdict

Husband criticises ‘barbaric and inhumane’ care and says he has yet to find out why his wife died

Fri, Apr 19, 2013, 20:08

During seven days of often graphic and upsetting evidence, the jury heard that Mrs Halappanavar would probably still be alive today if the law had allowed an abortion as she miscarried before there was a real risk to her life, by which time it was too late to save her.

She was 17 weeks pregnant when admitted to the University Hospital Galway on October 21st last with an inevitable miscarriage.

She died from multi-organ failure from septic shock and E.coli, four days after she delivered a dead foetus.

Leading obstetrician Peter Boylan outlined a number of deficiencies in her care, but stressed that none on its own was likely to have resulted in Mrs Halappanavar’s death.

Ms Halappanavar died at the Galway hospital on October 28th last, having presented a week earlier with severe back pain. She was found to be miscarrying.The miscarriage continued for three more days during which time she developed severe sepsis.

The recommendations

1 The Medical Council should lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which would remove doubt and fear from the doctor and also reassure the public. An Bord Altranais should have similar directives for midwives so that the two professions always complement one another.

2 Blood samples should be properly followed up and proper procedures put in place to ensure errors don't occur. That would be a national recommendation.

3 Protocols should be followed in the management of sepsis and there should be proper training and guidelines for all medical and nursing personnel. And that would be a national recommendation.

4 Proper and effective communication to occur between staff on-call and a team coming on duty and a dedicated handover time to be set aside for such communications. That should be applied nationally.

5 Protocol for sepsis written by the department of microbiology for each hospital and each hospital directorate. And that should be applied nationally.

6 A modified early warning score chart should be adopted by all hospitals in the state as soon as practicable.

7 There should be early and effective communications with patients and/or their relatives to ensure that a treatment plan is readily explained and understood. And this should be applied nationally.

8 The medical notes and nursing notes should be separate documents and kept separate. And that should be applied nationally.

9 No additions should be made to the medical records of a deceased whose death is the subject of a coroner's inquiry. Additions may inhibit the inquiry and prohibit the making of recommendations which may prevent further fatalities. And that should be applied nationally.

Additional reporting: PA