The systems, not individuals, to blame?

A finding of medical misadventure was probably about as much as Praveen Halappanavar could have expected from the inquest into his wife Savita's death.

Even if Mr Halappanavar was still visibly angry about what he described as the "barbaric and inhumane" treatment his wife received in University Hospital Galway when speaking yesterday outside the inquest, this inquiry was never going to point the finger of blame at any individual member of staff. To do so would encroach on the realm of civil or criminal liability which is the proper remit of other courts.

Deficiencies in care
But the verdict from the jury of six men and five women went as near as possible to an expression of admonition against the hospital, in the context of the systems failures and deficiencies in care that were clearly demonstrated during the inquest.

The alternative verdict suggested by Galway West coroner Dr Ciarán MacLoughlin, a narrative or open verdict, would have been viewed as a cop-out, given the evident failings of the system in this case.

Dr MacLoughlin’s conduct of the inquest has won praise from all sides, and the thoroughness of his inquiries is reflected in the fact that this has been one of the longest single-person inquests in the history of the State.

Six months on from one of the biggest scandals to hit the Irish health system, another organ of the State has shown itself capable of conducting a thorough and independent investigation of this tragedy. So there is much to be proud of here, but this should not blind us to the fact that the inquiry possessed its own shortcomings.

All of the expert witnesses called to give evidence work, or used to work, in our own health system – thus the inquest lacked the perspective that an overseas expert witness might have brought to the hearings.

It will be interesting, therefore, to see how the HSE inquiry into the case, which is chaired by a UK-based obstetrician, will review the hospital’s treatment of Ms Halappanavar. This inquiry, too, is oriented more towards identifying systems failures than apportioning blame to individuals, so perhaps we should not expect any great differences. (In which case, one might ask, why the need for two separate inquiries?)

At least one crucial witness, the midwife who cared for Ms Halappanavar on the morning of Wednesday, October 24th last, could not be called because she has been certified as medically unfit to do so. Neither has she made a statement, so we remain in the dark as to why the patient’s deterioration at this vital time was not picked up on more quickly and more urgently.

We did learn the origin of the “Catholic country” remark, but it only emerged in direct evidence; there was no mention of it in midwife Ann Maria Burke’s draft statement and the hospital never provided any explanation before this. It would have been helpful if this particular issue could have been clarified a long time ago, but it was never central to the main issue of how Ms Halappanavar came to die.

Conflict of evidence
Dr MacLoughlin tried, but failed, to resolve a conflict of evidence between a doctor and a midwife who saw Ms Halappanavar on Tuesday evening/ Wednesday morning. Ms Burke says she told Dr Ike Uzochukwu about her heightened pulse but he denies this. The coroner recalled both witnesses but they both stuck to their evidence.

The effect of the inquest on the wider political debate about abortion should be to fortify the Government’s intention to legislate on the issue, as promised shortly. This case has nothing to say on the controversial issue of allowing termination because of the risk of suicide, but it does illustrate how little time obstetricians have to make decisions in the face of rapidly spreading infections and how unsatisfactory the present guidelines are. It also shows that no matter how rare a condition is, it does happen and individual lives are at stake.

Aside from Praveen Halappanavar, the pivotal witness was Dr Peter Boylan, former master of the National Maternity Hospital. His assertion that Ms Halappanavar would probably be alive today if she had been given an earlier termination garnered the headlines, but it was his assessment of the care given to her that softened the blow for the staff at the hospital.

In Dr Boylan’s view, none of the mistakes made along the way made any difference to the eventual outcome.

He described as “entirely appropriate” the treatment given to Ms Halappanavar on the day of her admission, when she was first diagnosed with back pain and sent home. On returning to the hospital that day, she later had a blood test which wasn’t properly followed up on.

He was sympathetic to Dr Uzochukwu’s failure to take vital signs early on Wednesday morning, arguing that he was busy, and a doctor “couldn’t be in two places at the same time” and was justified in not waking a sleeping patient.

Another expert witness, microbiologist Dr Susan Knowles, noted that Ms Halappanavar was not given a vaginal examination or checked for leaking of amniotic fluid on the day she was admitted.

She took a sterner view of the failure to take vital signs and also queried the absence of a plan to deliver the patient's foetus when she was diagnosed with sepsis on Wednesday. Dr Knowles also personally disagreed with the antibiotics prescribed at this point by Ms Halappanavar's consultant, Dr Katherine Astbury; at this point, antibiotics and the prompt delivery of the foetus were the two ways of fighting the infection rapidly gaining hold of the patient.

Dr Boylan said delivering the foetus by administering drugs would have taken some hours anyway but little expert evidence seems to have been given in relation to the possibility of surgically removing the foetus at this point on the Wednesday.

Dr Astbury said she had never carried out such a termination.

Systems failures
All of the systems failures are well known by now: the failure to follow up blood tests; the failure to make regular observations; and retrospective entries made to medical records.

Overall, this means we are left with a generalised blaming of the system, while no individual member of staff is held to account. But is this good enough?