Key questions the report must address

ANALYSIS:The inquiry may have identified issues related to the availability of abortion

The leaking of a draft Health Service Executive (HSE) report into the death of Savita Halappanavar has been deeply upsetting for her husband.

It is also unfair on those who gave professional care to the late dentist.

It is difficult to analyse events with any certainty when dealing with partial and tentative findings in such a report.

Last October, Ms Halappanavar (31) died of blood poisoning seven days after being admitted to University Hospital Galway.

She had gone to the hospital with symptoms of an inevitable miscarriage when 17 weeks pregnant with her first child. Her husband and family subsequently raised questions about her care and, in particular, whether an earlier termination of the pregnancy could have saved her life.

An inevitable miscarriage occurs when on medical examination the neck of the woman’s womb is found to be open.

Even if there is still a sign of foetal life, there is no chance of the pregnancy continuing to term. In many cases the foetus will die and be evacuated naturally from the womb, which is why the initial management is often one of “watch and wait”.

However, when there is evidence of an amniotic fluid leak and the neck of the womb is open, the possibility of infection arises.

The next question is how far this infection will travel. Will it invade the wall of the womb or will it spread to the blood stream giving rise to blood poisoning (septicaemia)?

From the information made available to the Evening Herald, it appears the HSE inquiry may have identified issues related to the management of sepsis as well as the availability of abortion.

Among the key questions the final report is likely to address are:

Did the maternity unit at University Hospital Galway use a system called the Modified Early Obstetric Warning Score, which measures a pregnant woman’s temperature, pulse and blood pressure to detect whether a patient is deteriorating or not?

Were all laboratory tests followed up and acted on promptly?

At what point during Ms Halappanavar’s admission was a definitive diagnosis of sepsis secondary to miscarriage made?

When was antibiotic treatment started and by what route (oral or intravenous)?

The surgical evacuation of the source of infection is another treatment option. In this case, that would mean carrying out an abortion. When was it first considered and was there any delay in carrying out the procedure?

Once severe sepsis and shock were identified, how speedily was appropriate treatment initiated?

Was a full range of specialists involved in her critical care?

A final report is also likely to acknowledge that even with the appropriate and timely management of septicaemia and maternal collapse, there is a significant risk of death once a woman goes into septic shock.

Quite separate from checklists and guidelines, a crucial part of any inquiry will be to tease out from interviews with doctors and nurses how the clinical situation evolved – in particular, was Ms Halappanavar’s deterioration sudden or gradual?