Key factors in the death of Savita Halappanavar included multiple failures by clinical staff to properly assess or monitor her condition, according to a Health Service Executive review group report published today.
Mrs Halappanavar died of septicaemia in her 17th week of pregnancy at Galway University Hospital last October.
The circumstances of her death resulted in public outcry over the State’s abortion laws.
The report, described by Minister for Health James Reilly as a “hard-hitting report which spares nobody and doesn’t pull any punches”, identifies three main factors which led to Ms Halappanavar’s death.
- A failure to adhere to clinical guidelines for prompt and effective management of sepsis when it was diagnosed
- Not offering all management options to the patient as she experienced inevitable miscarriage, even though the risk she faced increased from the time her membranes ruptured
- Inadequate assessment and monitoring that would have allowed the clinical team to recognise and respond to the signs that her condition was deteriorating.
The report, which does not mention any names, also makes significant recommendations aimed at improving legal clarity and medical handling of complicated obstetric emergencies, including sepsis which led to Mrs Halappanavar’s death.
It found an apparent over-emphasis on the need not to intervene until the foetal heartbeat stopped and not enough emphasis on the need to focus on monitoring and managing the risk of infection. “The interpretation of the law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard,” the report added.
The report also sheds some new light on additional failures in the handling of Mrs Halappanavar’s condition. For example, on the day she was admitted to hospital the report states that no ultrasound was carried out by a specialist registrar because a probe used for scanning was broken.
Among the report’s main recommendations are:
- The Oireachtas should urgently consider amending the law - including any necessary Constitutional change - to help provide clinicians with a clear legal context for the management of "inevitable miscarriage"
- The HSE should develop and implement national guidelines on infection and pregnancy, along with education programmes to improve the quality of care in pregnancies complicated by infection
- Clear and precise national clinical guidelines to meaningfully assist clinical professionals who have to use their professional judgement in cases which may involve a rapid deterioration or emergency
The report was finalised by an inquiry team chaired by UK obstetrician Prof Sabaratnam Arulkumaran.
Today’s report comes just hours after the Government published the Protecting of Life during Pregnancy Bill, aimed at clarifying the law for women who need access terminations and for the medical practitioners who have to deliver them. The Bill was published by the Government in the early hours of this morning.
The report was published two months after an inquest jury Galway ruled unanimously that Mrs Halappanavar’s death was by medical misadventure. The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar’s care before she died, but coroner Ciaran MacLoughlin said they did not contribute to her death.
Dr Reilly said the report will be referred to the Medical Council and to the Nursing and Midwifery Board of Ireland for consideration.
Dr Reilly said it raises several important issues in relation to professional practice. “I have serious concerns about what this report reveals. It is a hard-hitting report which spares nobody and doesn’t pull any punches. It lays bare a set of unacceptable factors that led to the tragic death of a young woman. We must study this report in great detail, learn the relevant lessons and consider how best to implement its recommendations.”
The Minister also expressed his concern for Praveen Halapannaver and his wife’s family. “They have had to endure a terrible loss that should never have occurred. We must all work together to ensure that the lessons are learned and implemented to prevent such a tragedy occurring again,” he said.
In his report, Dr Arulkumaran said the Halappanavars had inquired about the possibility of having a termination but that this was not offered or considered possible by the clinical team until the afternoon of Wednesday, October 24th because of legal constraints.
Medics in Ireland had to be sure there is a real and substantial risk to the woman’s life in order to grant a termination. Dr Arulkumaran said the plan was to “await events”, which he said is appropriate provided it is not a risk to the mother or foetus.
“Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have led to reconsideration of the need to expedite delivery,” he said. “Monitoring and adherence to guidelines for the prompt and effective management of sepsis would likely have helped to prevent rapid deterioration of the patient. Delaying adequate treatment including expediting delivery in a clinical situation where there is prolonged rupture of the membranes and increasing risk to the mother can, on occasion, be fatal.”