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
Today’s report comes just hours after the Government published the Protecting of Life during Pregnancy Bill, aimed at clarifying the law for women who need access terminations and for the medical practitioners who have to deliver them. The Bill was published by the Government in the early hours of this morning.
The report was published two months after an inquest jury Galway ruled unanimously that Mrs Halappanavar’s death was by medical misadventure. The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar’s care before she died, but coroner Ciaran MacLoughlin said they did not contribute to her death.
Dr Reilly said the report will be referred to the Medical Council and to the Nursing and Midwifery Board of Ireland for consideration.
Full text of HSE review into death of Savita Halappanavar
Dr Reilly said it raises several important issues in relation to professional practice. “I have serious concerns about what this report reveals. It is a hard-hitting report which spares nobody and doesn’t pull any punches. It lays bare a set of unacceptable factors that led to the tragic death of a young woman. We must study this report in great detail, learn the relevant lessons and consider how best to implement its recommendations.”
The Minister also expressed his concern for Praveen Halapannaver and his wife’s family. “They have had to endure a terrible loss that should never have occurred. We must all work together to ensure that the lessons are learned and implemented to prevent such a tragedy occurring again,” he said.
In his report, Dr Arulkumaran said the Halappanavars had inquired about the possibility of having a termination but that this was not offered or considered possible by the clinical team until the afternoon of Wednesday, October 24th because of legal constraints.
Medics in Ireland had to be sure there is a real and substantial risk to the woman’s life in order to grant a termination. Dr Arulkumaran said the plan was to “await events”, which he said is appropriate provided it is not a risk to the mother or foetus.
“Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have led to reconsideration of the need to expedite delivery,” he said. “Monitoring and adherence to guidelines for the prompt and effective management of sepsis would likely have helped to prevent rapid deterioration of the patient. Delaying adequate treatment including expediting delivery in a clinical situation where there is prolonged rupture of the membranes and increasing risk to the mother can, on occasion, be fatal.”