Savita Halappanavar inquest
Sir, – The recent inquest on Savita Halappanavar has raised important issues about hospital infection in obstetrics. Much of the public attention appears to have been directed at the expert opinion of Dr Peter Boylan who suggested that Irish law prevented necessary treatment to save Ms Halappanavar’s life. We would suggest that this is a personal view, not an expert one.
Furthermore, it is impossible for Dr Boylan, or for any doctor, to predict with certainty the clinical course and outcome in the case of Savita Halappanavar where sepsis arose from the virulent and multi drug-resistant organism, E.coli ESBL.
What we can say with certainty is that where ruptured membranes are accompanied by any clinical or bio-chemical marker of infection, Irish obstetricians understand they can intervene with early delivery of the baby if necessary. Unfortunately, the inquest shows that in Galway University Hospital the diagnosis of chorioamnionitis was delayed and relevant information was not noted and acted upon.
The facts as produced at the inquest show this tragic case to be primarily about the management of sepsis, and Dr Boylan’s opinion on the effect of Irish law did not appear to be shared by the coroner, or the jury, of the inquest.
Obstetric sepsis is unfortunately on the increase and is now the leading cause of maternal death reported in the UK Confidential Enquiry into Maternal Deaths . Additionally there are many well-documented fatalities from sepsis in women following termination of pregnancy. To concentrate on the legal position regarding abortion in the light of such a case as that in Galway does not assist our services to pregnant women.
It is clear that maternal mortality in developed countries is rising, in the US, Canada, Britain, Denmark, Netherlands and other European countries. The last Confidential Enquiry in Britain (which now includes Ireland) recommended a “return to basics” and stated that many maternal deaths are related to failure to observe simple clinical signs such as fever, headache and changes in pulse rate and blood pressure. Many of the failings highlighted in Galway have been described before in these and other reports.
The additional problem of multi-resistant organisms causing infection, largely as a result of antibiotic use and abuse, is a serious cause of concern and may lead to higher death rates in all areas of medicine.
Ireland’s maternal health record is one of the best in the world in terms of our low rate of maternal death (including Galway hospital). The case in Galway was one of the worst cases of sepsis ever experienced in that hospital, and the diagnosis of ESBL septicaemia was almost unprecedented among Irish maternity units.
It is important that all obstetrical units in Ireland reflect on the findings of the events in Galway and learn how to improve care for pregnant women. To reduce it to a polemical argument about abortion may lead to more – not fewer – deaths in the future. – Yours, etc,
Dr JOHN MONAGHAN, DCH FRCPI FRCOG Consultant Obstetrician/Gynaecologist, Portiuncula, Galway; Dr CYRIL THORNTON, MB BCh MRCOG, Consultant Obstetrician/Gynaecologist, Cork Clinic; Dr EAMON Mc GUINNESS, MB BCh MRCOG, Consultant Obstetrician/Gynaecologist, Mount Carmel Hospital, Dublin; Dr TREVOR HAYES, MB BCh FRCS MRCOG, Consultant Obstetrician/Gynaecologist, St Luke’s General Hospital, Kilkenny; Dr CHRIS KING, MB DCH MRCOG Consultant Obstetrician/ Gynaecologist, Letterkenny General Hospital; Dr EILEEN REILLY, MB ChB MRCOG, Consultant Obstetrician/ Gynaecologist, Galway Clinic; Prof JOHN BONNAR, MD FRCPI FRCOG, Prof Emeritus Obstetrics & Gynaecology, Trinity College Dublin; Prof EAMON O’DWYER, MB MAO LLB FRCPI FRCOG, Prof Emeritus Obstetrics & Gynaecology, NUI Galway; Prof STEPHEN CUSACK, MB BCh FRCSI, Consultant in Emergency Medicine, Cork University Hospital; Dr RORY PAGE, MB BCh FFA RCSI, Consultant Anaesthetist, Cavan General Hospital; Dr JAMES CLAIR, MB BCh PhD FRCPath, Consultant Microbiologist, Mercy University Hospital,