Editor’s note. Virtually everyone, pro-life and pro-abortion alike, would agree that the dramatic changes in the laws governing abortion in Ireland stem from the tragic death of Savita Halappanava nearly a year ago. Pat Buckley described how “The tragic death of Savita Halappanavar was very effectively exploited to begin the process of the introduction of abortion into Ireland.” The false narrative was that the country’s strong pro-life laws were responsible for her October 28, 2012, death from sepsis. But as the following report—based on news accounts from, among other places, the wildly pro-abortion Irish Times—demonstrates, her death was because the hospital missed every sign.
As the opening paragraph in yesterday’s Irish Times story explained, “University Hospital Galway failed to provide Savita Halappanavar with ‘the most basic elements of patient care’ and failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner, according to a report by the State’s health watchdog.”
The hospital where Savita Halappanavar died almost a year ago failed to give her “even the most basic elements of patient care”, a new damning investigation has found. The investigation conducted by the Health Information and Quality Authority (HIQA) identified thirteen “missed opportunities” where appropriate intervention “may potentially have resulted in a different outcome for her”. Mrs. Halappanavar, who was 17 weeks pregnant, died of sepsis at University Hospital Galway on October 28 last year following a miscarriage.
The HIQA report said that following the rupture of her membranes Mrs. Halappanavar should have received four-hourly observations, including checks on her temperature, heart rate, breathing and blood pressure. This did not happen, however, and hospital staff failed to act in a timely way to respond to her deterioration. By the time she was admitted to the critical care unit it was too late.
Among the key findings of the report are:
– The hospital did not follow its own guidelines on early warning alerts for a patient who could be deteriorating.
– It also ignored its guidelines on sepsis and pre-term pre-labour rupture of the membranes.
– Vital information about her condition was not shared by doctors looking after her.
– She was placed in a ward that was unsuitable for someone at risk of clinical deterioration which had not enough staff qualified to treat patients there.
“The consultant, NCHDs and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time,” according to the report. “However, this did not happen.” It says the most senior clinical decision maker involved in the provision of care at any given time should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly. “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”
The 257-page report from HIQA is the third report into Mrs. Halappanavar’s death, and follows a coroner’s inquest and an inquiry by the HSE. It says the clinical governance arrangements within the hospital failed to recognise that vital hospital policies were not in use and points out that the Galway hospital developed a local Modified Obstetric Early Warning Score chart in 2009 but this was not in use on the ward three years later, in October 2012. It says there was no formal clinical escalation protocol and no emergency response team in place at the hospital and while sepsis guidelines were in place, clinical governance arrangements were “not robust enough” to ensure they were adhered to.
The report reveals wide variations in clinical care across different hospitals and units. It says there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, and no centralised approach to reporting maternal morbidity and mortality. As a result, it is impossible to assess properly the performance and quality of maternity services nationally, according to the report.
HIQA wrote to HSE director general Tony O’Brien several times this year seeking assurances in relation to the care of clinically deteriorating obstetric patients. Mr O’Brien responded to the authority, providing assurances on care in many hospitals, but HIQA says it remains concerned that the assurances were not in place for every hospital providing maternity services.