Medical Matters: Patient safety lessons are emerging from Savita inquest


Patients entering Irish hospitals expect to be treated in a safe manner. Doctors going to work in our hospitals do not plan to offer unsafe care to their patients. But things don’t always go according to plan and patients experience adverse outcomes in about 10 per cent of hospital admissions.

The vast majority of these outcomes are known side effects of treatments and procedures, with research showing about 40 per cent are related to surgical operations. Very few adverse events are the result of actual medical error, studies suggest.

Rather than engaging in a “blame and shame” exercise, a systems approach to adverse outcomes has been shown to better decrease the risk of similar events occurring in the future.

Which is why Galway West coroner Dr Ciarán MacLoughlin, presiding over the ongoing inquest into the death of Savita Halappanavar, has already identified two systems failures that occurred during her care at University Hospital Galway last October, and has hinted at some others.

System failures
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 Sunday, October 21st, last.

He said that 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 identified by the coroner was the failure to fully carry out four-hourly measurements of vital signs in a patient whose foetal membranes had ruptured, as the hospital guidelines stated.

Evidence emerged that in Savita’s case, the observation of her vital signs on the Tuesday night and Wednesday morning was incomplete.

Consultant obstetrician Dr Katherine Astbury stated she looks 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.

Expert witness consultant microbiologist Dr Susan Knowles highlighted how, even with the readings available, medical staff were not alerted to the deterioration in Savita’s condition earlier on the Wednesday.

Her blood pressure fell below 90mm Hg at 10am and dropped below 80mm Hg at midday. She had a persistently high pulse rate between 140 and 168 beats per minute since 6.30 that morning.

“Hypotension in a young woman is usually a late sign of deterioration. This should have been brought to medical attention sooner,” Dr Knowles said in her report.

Retrospective additions

Other issues with a potential impact on patient safety to emerge included the retrospective addition of clinical notes to the patient record.

Dr MacLoughlin was of the view that the number of such additions to Savita’s chart was excessive. Such additions, even when clearly marked, are frowned upon by medical regulatory bodies, although in this case there has been no evidence that any doctors made retrospective notes in her chart.

But nurses did add notes after the event on eight occasions, and while in five cases these additions were made within hours of the care they referred to being made given, some three notes were made in the weeks after Savita passed away.

Another safety issue connected to the hospital notes was the practice of nurses and doctors in the maternity unit using the same set of notes.

The coroner said he believed it would be preferable, in order to avoid confusion, if nurses and doctors worked from separate notes.

There is no form of medical care that is 100 per cent safe. But doctors and nurses have a duty to make the care they offer as safe as humanly possible.

We must ensure the lessons learned in this tragic case contribute to safer maternity care in Ireland.