Savita hospital review finds ‘reasonable compliance’

Ernst & Young finds no ‘residual actions’ on disciplining staff involved in late woman’s care

Savita Halappanavar died one week after she was admitted to University Hospital Galway more than two years ago, when she was 17 weeks pregnant and miscarrying. Photograph: The Irish Times

A review of the implementation of official recommendations following the death of Savita Halappanavar has found "a reasonable picture of compliance".

The review by consultants Ernst & Young found there were no "residual actions" for the Saolta Hospital Group to take in relation to disciplining staff involved in the treatment of Ms Halappanavar, who died at University Hospital Galway (UHG) more than two years ago.

The maternity unit at the hospital will ultimately have to be rebuilt to address “infrastructural deficits”, a second review has warned.

John Killeen, Interim Chair, speaking during the presentation of the report into the death of Savita Halappanavar. Photograph: Joe O’Shaughnessy.

Saolta Hospital Group, which includes UHG, presented the findings of the two reviews at a public board meeting in Galway.

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The EY review looked at its implementation of recommendations made by the Health Information and Quality Authority (Hiqa) in a report last year.

An internal review assessed compliance with the findings of a HSE investigation into Ms Halappanavar’s death, as well as the recommendations of the coroner.

The EY review found evidence the group was committed to implementing the recommendations and there was an action plan to achieve this.

Early warning systems

Progress has been made in the implementation of two early warning score systems for seriously ill patients and in the process of patient handover during staff changes.

The group would be better able to monitor outstanding actions by making them more specific and measurable, it said.

“Individual tasks need to be assigned to individuals who can be held to account for delivering these within clearly specified timeframes in the plan.”

Performance reports and risk registers would be more effective if they contained clear accountabilities and timeframes for action.

The review looked at progress made on 15 local recommendations, specific to UHG, which were made in the Hiqa report.

It did not examine another 19 recommendations of national import.

Of the 15 recommendations, it found four were fully implemented. Seven were partially implemented and in four cases some elements of implementation were in place, but further development was needed.

No recommendations fell into the worst category of “limited implementation”.

The consultants carried out a one-day spot check of healthcare records in the maternity unit and found sub-standard documentation across all grades of medical staff.

Revision required

They also found half of the 2,000 policies in place in the hospital were out of date or required revision.

In a separate report, Dr Pat Nash, clinical director of the Saolta group, found all the local recommendations arising from the HSE patient safety review and all of the coroner's local recommendations had either been fully implemented or had an implementation plan in place.

“A clear structure is in place at UHG to progress the implementation of the recommendations from the three investigations, with clear lines of responsibility/accountability,” he said.

“The priority areas for implementation in 2015 are development of up-to-date policies, procedures, guidelines and ensuring a robust audit monitoring structure is in place across the group; implementing and monitoring the identified actions from our self-assessment against the Hiqa standards; and further progressing the implementation of a comprehensive clinical audit structure across the group.

‘Infrastructural deficits’

“We will also need to address the infrastructural deficits in the maternity department. Whilst progress has been made, these are only interim measures. Ultimately the maternity unit will require a new build.”

The reviews do not deal with the disciplinary process for staff involved in the care of Ms Halappanavar, which the hospital says is complete.

In September, it said the actions of 30 staff were considered and it was found 21 had “no case to answer”.

Sanctions, including written warnings and more training, were imposed on up to nine other staff.

A number of cases are currently before the professional bodies for doctors and nurses, the Medical Council and the Nursing and Midwifery Board, but no public hearings have been held so far.

Ms Halappanavar died one week after she was admitted to the Galway hospital when she was 17 weeks pregnant and miscarrying.

Subsequent reports were critical of the failure of staff to detect a sudden deterioration in her condition following the onset of sepsis.

Paul Cullen

Paul Cullen

Paul Cullen is a former heath editor of The Irish Times.