Savita report stresses failure to record symptoms

Cascade of failures at Galway hospital highlighted

The HSE Inquiry on Savita Halappanavar's death chaired by Prof Sir Arulkumaran highlights a disastrous cascade of failures at Galway University Hospital (GUH).

The Coroner’s Inquest did likewise, but subsequent commentary diverted attention, suggesting that the law that was the primary problem.

Dr Arulkumaran does indeed say that that the law needs clarification, and no one disagrees with clarity. However, the kind of detail that complex medical situations require could never be the subject of legislation.

You could not write into law, for example, the exact moment at which a termination should be offered to a woman in Savita's terrible situation. That remains a matter of clinical judgement, though Medical Council guidelines would be of immense help.

The HSE Inquiry summarises the causal factors as the team’s failure to adequately diagnose the danger that Savita was in, and crucially, she was therefore not offered treatment to which she was entitled. The hospital also did not adhere to sepsis clinical guidelines even when it was diagnosed.

The Report cites one damning statistic. ‘Those presenting [in the second trimester] with a live foetus and bulging membranes are associated with infection in 77% of cases. Therefore, the presence of infection should have been assumed and the progression to sepsis closely monitored for.’

It has received little comment how much this report contrasts with Dr Peter Boylan’s expert opinion at the Coroner’s Inquest and in subsequent media interviews.

Dr Boylan’s testimony to the coroner says that he thought it ‘unlikely that the failure to note the elevated white blood cell count on admission, or repeat it had any material impact on the eventual outcome.’

When this writer suggested in a radio interview to Dr Boylan that the failure to repeat the white blood cell test was ‘hugely significant’, he replied, “It wasn’t. No. You’re completely wrong.”

Dr Arulkumaran says regarding Savita: ‘The patient’s white blood cell count on admission may have been due to pregnancy but was too high to be normal and was suggestive of possible infection in the absence of any other obvious causes at this time. However, these blood test results taken on the 21st of October 2012 were never followed up.’

Dr Boylan expert testimony says that on ‘Monday October 22nd, Ms Halappanavar’s temperature was normal on five readings, her pulse ranged between 90 and 102…none of the readings gave cause for concern…’ He also notes three pulse rates of 100 or over on Tuesday October 23rd, which he says was ‘in retrospect, (emphasis mine) was probably evidence of developing chorioamnionitis.’

In the same radio interview, he says of Monday and Tuesday: ‘She had a normal pulse, she had a normal temperature, it was only in the very early hours of Wednesday…’

In contrast, the HSE’s report says ‘The investigation team established that the patients pulse rate was recorded as more than 100 beats per minute on four prior occasions (102 p/m at 18.00hrs on 22nd of October [Monday}, 102 p/m at 21.40hrs on 22nd of October, 114 p/m at 19.00hrs on the 23rd of October [TUESDAY]and 108 p/m at 20.00 hrs on the 23rd of October).’

It elaborates: ‘A pulse rate greater than 100 should have triggered tests for white blood cell count/differential count and C-reactive protein and this would support a diagnosis of sepsis.’

In my opinion, this report completely vindicates Profs John Bonnar and John Monaghan and others, who repeatedly said that the problem was not the failure to provide an abortion on request, but the failure to see the significance of a cascade of symptoms, and to act appropriately by delivering the baby early.

Health cutbacks may also have played a serious part in this preventable tragedy. GUH had no modified Obstetric Early Warning Score observation chart system (mOEWS), the system Dr Arulkumaran says could have helped save Savita’s life.

In another non-Dublin maternity hospital, an obstetrician known to this writer paid for the printing of the mOEWS charts because there was no HSE money available.

The same obstetrician and a colleague then paid for twelve midwives to take an advanced life support in obstetrics course (ALSO), again because HSE funding was unavailable. An important element of ALSO training is to identify early signs of infection that indicate sepsis.

The obstetrician does not want to be identified, and brushes off suggestions of altruism. As he put it, he could not let women’s lives remain at risk just because it would cost him and a colleague a few grand.

This incident illustrates perfectly what is wrong with our current debate. We have a Bill which has the utterly misleading title, Protection of Human Life during Pregnancy, which instead mandates the taking of one human being’s life when another human being is in severe mental distress.

Yet we ignore that the HSE’s disgraceful state, in part at least due to austerity, meant that there was no money to pay for real life-saving measures or no enthusiasm to implement them. There are still questions to be answered about the impact of cutbacks in GUH. The politics of distraction, practiced daily by this government, and ably assisted by some commentators, allow us to go on ignoring that reality.