THE CORONER IN the Savita Halappanavar inquest charged the jury giving it a choice of two verdicts – a narrative verdict or a verdict of medical misadventure.

Dr Ciarán McLoughlin told the jury it could accept, reject or add to his recommendations after he summed up the evidence heard over the past two weeks.

In returning a verdict of medical misadventure, the jury ‘strongly endorsed’ the nine recommendations.

• You may recommend that the Medical Council lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which will remove doubt and fear from the doctor and also reassure the public. An Bord Altranais should have similar directives for midwives so that the two professions always complement one another.
• That blood samples are properly followed up and proper procedures are put in place to ensure errors don’t occur. That would be a national recommendation.
• Protocols are followed in the management of sepsis and there is proper training and guidelines for all medical and nursing personnel. And that would be a national recommendation.
• Proper and effective communication to occur between staff on-call and a team coming on duty and a dedicated handover time is set aside for such communications. That should be applied nationally.
• A protocol for sepsis written by the department of microbiology for each hospital and each hospital directorate. And that should be applied nationally.
• That a modified early warning score chart should be adopted by all hospitals in the state as soon as practicable.
• Early and effective communications with patients and/or their relatives to ensure that a treatment plan is readily explained and understood. And this should be applied nationally.
• That the medical notes and nursing notes should be separate documents and kept separate. And that should be applied nationally.
• No additions are made to the medical records of a deceased whose death is the subject of a coroner’s inquiry. Additions may inhibit the inquiry and prohibit the making of recommendations which may prevent further fatalities. And that should be applied nationally.

The inquest was a fact-finding mission about how the 31-year-old dentist died on 28 October while being treated at Galway University Hospital.

The verdict: Jury returns verdict of medical misadventure