Savita Halappanavar’s missed opportunities
The Health Information and Quality Authority identified 13 things that could have made a difference
Savita Halappanavar, who was 17 weeks pregnant, died of sepsis following a miscarriage at University Hospital Galway. Photograph: Joe O’Shaughnessy. 13/11/2012
The Health Information and Quality Authority identified, through a review of Savita Halappanavar’s healthcare records, 13 missed opportunities which, had they been identified and acted upon, might have potentially changed the outcome of her care.
1 October 21, 2012
Blood tests were taken after Ms Halappanavar was admitted to an inpatient room when a diagnosis of inevitable/impending pregnancy loss was made by the obstetrics and gynaecology registrar following clinical findings. These results showed an elevated white cell count which should have alerted staff to investigate the cause of this further.
Spontaneous rupture of membranes occurred. Four-hourly observations to include temperature, heart rate and respiration and blood pressure were not recorded. Prophylactic antibiotics to minimise the risk of infection were not prescribed.
3 October 22
Ms Halappanavar was reviewed by the consultant obstetrician in charge of her care. The team was aware that she had suffered a spontaneous rupture of membranes overnight. Her plan of care, following this, was that a foetal ultrasound scan would be taken with instructions to “await events”. Hiqa is of the opinion a more comprehensive plan of care should have been developed and documented following this clinical review.
4 October 22-23
Three recordings of low blood pressure and two of an elevated heart rate were documented. The clinical significance of these signs, over a 15-hour period, was not recognised by the clinical staff. They indicated signs of clinical deterioration, for which infection would be a likely cause.
5 October 23
Ms Halappanavar was reviewed by the consultant obstetrician in charge of her care. The clinical staff in charge and looking after her did not recognise, document or manage the risks in relation to her changing clinical state. For example, at this time, it was 24 hours since she had had a spontaneous rupture of membranes, after which time the risk of infection in the uterus increases.
6 October 23
Over a five-hour period, Ms Halappanavar had three recordings of an increasingly elevated heart rate. Staff did not recognise the significance of these recordings along with other clinical indications as an important indicator of clinical deterioration.
7 October 23-24
Ms Halappanavar complained of weakness. When staff caring for her contacted a non-consultant hospital doctor, the doctor was not
immediately available to come and review the patient. Given the seriousness of her condition, staff did not appear to have recognised the urgent need to request she be reviewed by another doctor.
8-10 October 24
Ms Halappanavar had a raised temperature, was shivering and had vomited. Staff did not recognise the significance of these clinical symptoms. Vomiting in a patient who was presenting clinical symptoms like this could potentially suggest sepsis.
11-12 October 24
Ms Halappanavar’s temperature
and pulse rate were elevated and her blood pressure was low. She was complaining of feeling weak, general body aches and had an offensive smelling vaginal discharge.
Following a diagnosis of “chorioamnionitis with probable sepsis”, evidence shows her treatment plan was not changed at this time.
13 October 24
Women with maternal infection can deteriorate rapidly from sepsis, to severe sepsis and then into septic shock. The doctors in charge of and caring for Ms Halappanavar, despite a diagnosis of chorioamnionitis with probable sepsis being made, did not appear to recognise the significance of this diagnosis and the continuing deteriorating clinical signs.
In line with local guidelines, this should have prompted contact with a consultant microbiologist and other senior members of the multidisciplinary team, including critical care personnel who should be involved early in the process, if sepsis is suspected or diagnosed to discuss ongoing management.