University Hospital Galway apologises over death

Hospital says it has implemented changes to avoid a repeat of events surrounding death of Savita Halappanavar

Report identifies multiple failures in treatment of Savita Halappanavar

Thu, Jun 13, 2013, 18:36

University Hospital Galway today apologised to Savita Halappanavar’s husband Praveen and the Halappanavar family “for the events related to his wife’s care that contributed to her tragic death” .

In a statement issued on behalf of the hospital, Dr Patrick Nash, who was clinical director and commissioner of the inquiry into the death of Ms Halappanavar, said the hospital is “committed to operating to the highest standards” and wanted to reassure all concerned that changes have been implemented “to avoid the repeat of such an event.”

Dr Nash noted Mr Halappanavar has stated that he does not want any other woman to go through what happened to his wife. “The recommendations from this review will result in changes and improvements that will minise the risk of this ever happening again in Ireland, ” Dr Nash said in the statement.

Ms Halappanavar’s death was the first direct maternal death at the hospital in 16 years, Dr Nash said, adding that “it is clear from the report that there were failures in the standard of care provided at University Hospital Galway.”

The hospital has undertaken “a number of significant improvements” in response to the interim safety recommendations issued to the hospital.

These include:

- the implementation of early warning scoring systems

- the education of all staff in the recognition, monitoring and management of sepsis and septic shock; and

- the introduction of new multi-disciplinary team-based training programme in the managment of obstretric emergencies, including sepsis.

The hospital has also improved communications processes and are implemening procedures for doctors’ handovers.

Dr Nash said the hospital and the HSE will “work to fully implement all of the recommendations arising from the report”.

HSE

In a statement issued by the HSE accompanying the publication of the report, the HSE and University Hospital Galway apologised “unreservedly” to Mr Halappanavar “for the tragic and untimely death of his wife”.

The HSE said it had commissioned the report “to establish the facts and contributory factors” leading up to the death of Ms Halappanavar “and to provide recommendations”.

“The investigation to identify key causal factors involved a systems analysis of relevant records, interviews with 19 members of staff involved in Ms Halappanavar’s care and the review of local, national and international guidelines.

“Mr Halappanavar inputted to the investigation process through his representatives,” the statement said.

Outlining three causal factors identified by the investigation team, the statement said University Hospital Galway has already undertaken “significant measures in response to the interim recommendations.”

The three causal factors were:

- Inadequate assessment and monitoring of Ms Halappanavar that would have enabled the clinical team in UHG to recognise and respond to the signs that her condition was deteriorating

- Failure to offer all management options to Ms Halappanavar who was experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to her was increasing with time from the time that her membranes had ruptured.

- UHG’s non-adherence to clinical guidelines relating to the prompt and effective management of sepsis, severe sepsis and septic shock from when it was first diagnosed.

The statement said UHG has “improved communications processes” and is “implementing new procedures for doctors’ handovers”.

“Both University Hospital Galway and the HSE will work to fully implement all of the recommendations arising from the report in all hospitals,” the statement said.