Inquest gives insight into medical decision making on termination of pregnancy

Medical View: There were two system failures at University Hospital Galway last year

University Hospital Galway. Photograph: Eric Luke

University Hospital Galway. Photograph: Eric Luke

 

Two important conclusions emerged from the inquest yesterday into the death of Savita Halappanavar, the dentist who died from septicaemia when 17 weeks pregnant.

Coroner Ciarán MacLoughlin identified two system failures during her care at University Hospital Galway last October. The first involved the failure of medical staff to follow-up the results of a full blood count (FBC), which was taken on her admission on October 21st. He said each clinical team in the obstetrics department had a responsibility to check blood results of patients under their care. It subsequently emerged the FBC had shown a significantly raised white cell count, an indication of possible infection.

The second system failure was the failure to fully carry out four-hourly measurements of vital signs of a patient whose foetal membranes had ruptured. Evidence emerged that the observation of her vital signs on Tuesday night and Wednesday morning was incomplete.

Consultant obstetrician Dr Katherine Astbury said she looked for the trend in these readings and that the omission of one set of readings in a 24-hour period would not hamper this ability. However the coroner confirmed there had been a failure in the system of recording Savita’s vital signs by nurses in the obstetrics unit at a crucial time in her care.

We also got some insight into the decision-making of obstetric consultants when considering a termination in the second trimester. Dr Astbury made it clear that in addition to the relevant Medical Council guideline on the matter, she also required there to be a balance of probabilities (51 per cent) of a risk to the life of a mother.

Having decided to proceed with a medical, as distinct from a surgical, induction of abortion, on Wednesday afternoon she sought a second opinion from Dr Geraldine Gaffney, the clinical director of the obstetrics department.

Dr Gaffney told the inquest she was in agreement with her colleague’s assessment that notwithstanding the presence of a foetal heartbeat, the risk to Savita’s life was such as to warrant an abortion.

The inquest was told the preferred method of termination in a woman who is 17 weeks pregnant is the administration of the drug misoprostol. It can be given orally or via a vaginal pessary, with 200mg tablets given every six hours up to a maximum of four tablets. The drug stimulates contractions in the uterus, thereby inducing labour. Dr Astbury said the process usually took several hours and was usually complete within 24 hours of the first administration of medication.

Earlier, under cross examination, Dr Astbury said that even after foetal membranes have ruptured at 17 weeks, there was a 12-18 per cent possibility of the foetus surviving until viability at 23/24 weeks gestation. However she said medical literature showed there was a 30-40 per cent risk of intrauterine infection once membranes had ruptured, with the risk increasing the more time that elapsed. But at the point of rupture, the risk of the mother dying was just 0.1 per cent.

Other issues of medical significance with a potential impact on patient safety included the retrospective addition of clinical notes to patients’ records. Dr Mac- Loughlin was of the view that the number of such additions to Savita’s chart was excessive.

Such additions are frowned upon by medical regulatory bodies, although in this case there has been no evidence any doctors made retrospective notes in her chart.He was also critical of the practice of nurses and doctors in the maternity unit using the same set of notes. Clinical midwife manager Ann Maria Burke agreed with the coroner, saying she now believed separate notes would be preferable.