HSE promises full Savita Halappanavar follow-up

The wards in which Savita Halappanavar was cared for at Galway University Hospital had been adequately staffed and no consultant obstetrician was on leave at the time, the HSE’s national director of quality and patient safety has said.

Dr Philip Crowley acknowledged questions had been raised about staffing levels at the hospital in the days leading up to Ms Halappanavar’s death last October.

No answers were available to this question when a review into her death was published by the HSE on Thursday but Dr Crowley said the hospital had since confirmed that the wards caring for her had been adequately staffed and no consultant obstetrician was on leave at the time. Staffing levels were “normal, safe and adequate”.

'Not identified'
A hospital spokesman said staffing levels were not identified in the report as either causal or contributory factors in her death.

“Similarly, the coroner’s inquest examined in great detail over seven days and many witnesses all of the events leading up to Savita’s death. Staffing levels were not identified as a significant factor.”

Asked what measures the hospital had implemented since a serious but non-fatal case of sepsis in 2009, the hospital spokesman said new sepsis guidelines were introduced in 2012.

It emerged from both investigations into Ms Halappanavar’s death – an inquest and the HSE investigation – that these guidelines were not followed.

The Health Service Executive has said all the recommendations of the clinical review into the death of Ms Halappanavar will be fully implemented.

The hospital had already implemented all the interim recommendations made by the review team late last year, and a committee had been established to ensure that the remaining recommendations would also be acted upon, it said.

'Rare occurrence'
Dr Crowley said Ms Halappanavar's death from sepsis was a "rare occurrence", and it was clear from the HSE report that "staff did not recognise what was happening".

“Sepsis is becoming more common. As a health service we need to redouble our efforts to train people in the recognition and very aggressive management of sepsis and that is what we are going to do,” he said.

Speaking on RTÉ, Dr Crowley pointed out that a maternal early-warning score system had been introduced in all 19 hospitals with maternity units, as recommended by the report.

After the inquest last April and the HSE report, a third investigation into Ms Halappanavar’s death, by the Health Information and Quality Authority, is due to be published in the autumn.

This report will also be systems-oriented, according to sources, but it is not clear whether it will deal with staffing, rostering and resource issues.

Patient Focus has called for a review into the manner in which deaths and injuries are investigated in Irish hospitals to ensure that acceptable standards are being reached.

Learning
"We hope the learning acquired by the HSE as a result of the public scrutiny involved in this case will now be rolled out to the conduct of other reviews and investigations.

“Sadly many injuries and deaths suffered by patients are not investigated promptly, thoroughly and fairly. Standards are variable throughout the country and risk management processes are often rudimentary.”

The group said private hospitals were of particular concern because they were “outside any regulation whatsoever”.

The HSE has stressed that while Savita’s husband, Praveen Halappanavar, was disappointed that he did not receive a copy of its review into his wife’s death before Monday, a copy of the report was emailed to his solicitor at teatime on Wednesday to give him some time to read it before it was published at 2.30pm on Thursday.