Editor’s note. This analysis came from Lifezine, an Irish pro-life site.
The inquest into the death of Savita Halappanavar has uncovered a series of errors and ‘systems failures’ in University Hospital Galway in the preceding days. A crucial blood test that should have triggered alarm bells was not followed up on, and the consultant obstetrician was unaware of “significant” information written by another doctor in the patient’s notes.
Coroner Dr. Ciarán MacLoughlin believes he has identified a number of systems failures that occurred in Mrs. Halappanavar’s treatment, including a failure to monitor her condition regularly and a failure to pass on the result of key medical tests and observations.
Consultant Obstetrician Dr. Katherine Astbury said she would have begun to terminate the pregnancy sooner, regardless of a foetal heartbeat, if she had been aware of a junior doctor’s note that the patient was suffering from severe sepsis. She admitted at the inquest that on the day Mrs. Halappanavar miscarried, October 24, she did not know a junior colleague had put on her chart at 6.30am that he suspected Mrs. Halappanavar was suffering from sepsis caused by chorioamnionitis, an infection of the foetal membrane.
She said that when she examined Mrs. Halappanavar at 8.30am, her vitals had dropped and she believed she had sepsis, not severe sepsis, and admitted that her registrar did not read the earlier entry reporting a foul-smelling discharge, a sign of chorioamnionitis. Dr. Astbury insisted had she known this, she would have started the steps for a termination then regardless of a heartbeat, instead of ordering tests to check for a urine infection and deciding to terminate at 1pm when severe sepsis was diagnosed.
Mrs. Halappanavar, 31, delivered a dead baby daughter on that Wednesday and died the following Sunday of a heart attack caused by septicaemia due to E.coli.
Dr. Astbury also admitted she was unaware of an abnormal white blood cell count as test results had not been passed on to her team from the weekend staff on-call and that Mrs. Halappanavar’s clinical signs were not checked every four hours, in breach of hospital policy, after her membranes ruptured in the early hours of Monday morning.
Dr. Astbury said she refused to terminate the pregnancy two days after Mrs. Halappanavar was admitted as there was not at that stage a risk to her life. She explained that when she reviewed Mrs. Halappanavar on October 23, the patient was very upset. When she had enquired about medication for a termination, she had explained that the legal position in Ireland did not permit her to terminate the pregnancy at that time. Mrs. Halappanavar was well and there was no suggestion of a risk to her life, so she could not offer her a termination then. Asked if she had used the phrase “… because this is a Catholic country”, Dr. Astbury said it was not something she would say.
Dr. Anne Helps, Dr. Astbury’s registrar in October, said it was “possible” she did not tell her consultant of a significant indicator she had sepsis. Dr. Helps also did “not recall” whether she looked at Mrs. Halappanavar’s medical notes on the morning a colleague had told her about his concerns about her deteriorating condition.
Dr. Helps said she had had Mrs. Halappanavar’s chart in her hands during the ward round with Dr. Astbury at 8.20am on Wednesday October 24. She said she had had an oral report “in the corridor” from Dr. Ikechuckwu Uzockwu, the senior house officer on duty the night before, who had been concerned at 6.30am about Mrs. Halappanavar’s temperature of 39.6 degrees, elevated heart rate of 160bpm and a foul-smelling vaginal discharge.
“It was a conversation in the corridor without the records. [Dr. Uzockwu] just said to me, ‘Your patient spiked a temperature and is feeling unwell.’ There was no mention of a foul-smelling discharge.” She said he had documented his concerns in the notes.
Midwife manager Ann Maria Burke was questioned by the coroner on Dr. Uzockwu’s evidence. He had said that on October 23, Mrs. Halappanavar was complaining of weakness, but her blood pressure and temperature were within normal range. He had not received any communication about an elevated pulse, he told the inquest on Tuesday. Mrs. Burke, however, insisted that she had “definitely” told him about the pulse rate. Cross-examined later she said: “I’m absolutely certain I told him about the elevated pulse rate”.
Both witnesses are to be recalled in an effort to resolve the conflict of evidence.
Mrs. Burke also apologised for telling Mrs. Halappanavar she could not have a termination in Ireland because it was a “Catholic thing”. She admitted she made the remark but insisted she meant it in kindness.
“It was not said in the context to offend her,” she said. “I’m sorry how it came across. It does sound very bad now but at the time I didn’t mean it that way.”
She said it was more to give information and to throw light on Irish culture.
“I did mention ‘a Catholic country’, I didn’t mention it in a hurtful context, it was in context of a conversation we had . . . She talked about India, she mentioned there was no problem taking a baby in India, and the Hindu faith was mentioned in conversation. I did explain to her because I knew it wasn’t possible to induce her because, I had been informed by the consultant, the foetal heartbeat was there. It was not in the context of offending her and sorry if it came across that way. I don’t think I came across as insensitive at the time but I have to say it does sound very like that now.”
“I shouldn’t have said it but it came out the wrong way.” It was a chat and had nothing to do with the provision of care, she told the inquest.
Consultant Microbiologist Dr. Susan Knowles, an expert witness, told the inquest that there was poor documentation of the patient’s worsening condition. She said most medical notes from a crucial period of the onset of sepsis were made retrospectively. Some were made shortly after the events of the afternoon of Wednesday, October 24, but others were added on November 7, 8 and 12.
Dr. Knowles said a white cell count reading from blood test results should have been checked to alert staff that she had more severe sepsis than initially thought.
When Mrs. Halappanavar complained of feeling cold and shivery at 4.15am on the morning of October 24, all her vital signs should have been recorded. This did not happen.
Dr. Knowles said that when she was diagnosed to be clinically septic at 6.30am that morning, she was examined promptly and that intravenous antibiotic treatment followed. This treatment should have been actively followed up afterward rounds at around 8.20am.
Dr. Knowles agreed that delivery of the baby would be essential where the mother was diagnosed with chorioamnionitis. “Delivery will naturally happen but if you suspect chorioamnionitis you may have to expedite that,” she said. She told the inquest that delivery of the baby was not warranted before chorioamnionitis was suspected on Wednesday, October 24. She added that it was her understanding that there was no substantial risk to Savita’s life before the Wednesday.
Dr. Knowles said the management of Mrs. Halappanavar’s condition from 1pm that day was of a high standard.
She said the team of medics caring for Mrs. Halappanavar should have been aware of an elevated white cell count reading sooner than was the case. This is one of the indicators for the presence of sepsis. Dr. Knowles said the pattern of vital signs in the case of Mrs. Halappanavar were also important. They should have all been monitored and recorded. This did not happen.
She agreed that it was clear that the GUH protocols for dealing with sepsis infection had not been adhered to. Dr. Knowles said the antibiotics recommended as part of those guidelines had not been administered until around 1pm on Wednesday, October 24.