If I may explain why termination was not mentioned in the notes – the medical records are a recording of what actually happened – so for example, the patient asks for a slice of toast and a cup of tea – if the nurse refused, this would not have been recorded on the patients’ notes, however if the nurse says yes, then this is recorded in notes. The reason we don’t record discussions is time constraint, especially when the patient is in labour, which would have a minute by minute time scale in the notes.
RE HIQA: Actually, the members of HIQA are publicly appointed, the recruitment was in public, there is nothing hush-hush about them, all you need to do is look at their track record RE closing down hospital wards, or compelling the HSE to act upon unpalatable changes. I would tend to agree with you though, I’m not sure that this case falls within the remit of HIQA, but time will tell!

@James Your reply sort of confuses me even more. I am unclear why a request for tea and toast would be recorded but time constraints would preclude recording a request for termination?

You seem to be saying that if the nurse had declined to provide toast, the request would not have been recorded (which seems… strange) – are you saying that a request for termination would only be recorded if the response was positive?

It seems you are allowing for two options here:

1. The request was made, but not considered at all important (less important than a request for tea and toast).
2. The request was never made ie her husband.. just made it up? Imagined it?

Wait…. I sort of get it more now.

The request for toast resulted in toast being provided which is an action and so was recorded. If a request was made for any treatment and the treatment was not provided, no action occurred and thus nothing was recorded. Ok, sorry, I get that now.

Can I ask though, if a request for a treatment was made which was taken sufficiently seriously that it resulted in the attending doctor leaving the patient to consult with other doctors before providing a response, would that not be something that would be routinely recorded?

Hi Katie, apologies – nights have their negative effects!
To put it another way, regardless of how important or unimportant a request is, they are only recorded when the response is positive. So if she had asked for a termination, and the response was positive the request would have been noted in the records. The medical records are a record of what actually happened. What I would say however is that the request for termination could most likely have been recorded in the nursing notes, as this provides a more un-scientific recording of the patient’s stay, looking at the patient in a more pastoral care kind of light, a more holistic fashion, not from a medical point of view.
If another doctor assessed the patient, which would be required if the patients’ doctor looked for a second opinion from a colleague, then yes, this would be recorded in the notes – regardless of whether the patient physically say the second doctor or not.

Just to add to that this is why it is extremely important an inquiry is carried out quickly and efficiently while the event is fresh in people’s minds. The more time that passes the more events become fogged, or unclear, minute details are forgotten, and confusion takes over. The medical and nursing notes are not the be all and end all, staff interviews are every bit important, and it is of paramount importance that these are carried out ASAP.

@James, thank you, that makes sense.

I can understand perfectly how all requests are not recorded (I imagine my heartfelt request during labour that those in attendance should ‘Just kill me now’ didn’t make it to my records!). I just think that the position that doctors find themselves in when it comes to abortion is so murky and grey that it lends itself to missing information in notes. Not through maliciousness or an attempt to cover their tracks, but because doctors who genuinely want to help their patient (ie the vast, vast majority) find themselves forced to give advice that might be damaging to them were it to be recorded.

Also, I agree with you that HIQA have been excellent, I just think that a completely independent inquiry may be the only hope. This just gets more and more difficult and with every day that passes and I get more despairing about the truth every being fully known, whatever that truth is.

@ James. I agree with Katie. Asking for a termination is not a trivial matter. This should have been recorded.

Regarding hiqa, though independent it will not meet mr halappanavar’s request for cross examination of witness’s/ staff under oath.

Hi Irene, I absolutely agree with you, asking for a termination is never a trivial matter, nor did I suggest such a thing, my apologies if it was perceived that I did, but I don’t think it was.
The medical records of a patient exist to portray an accurate picture of the patient’s interaction with a health service from a medical point of view. (I would add, things like what a patient eats is always recorded as this may impact treatment options, just to clear up why eating habits are written in, and requests for termination are not). The reason (I would imagine) that request for termination was not mentioned early on in the notes (I have read reports that it was mentioned in later days) is because it could not have been carried out due to the grey area that exists RE termination. As a treatment option becomes more likely to take place the more likely any requests for that treatment option by the patient will make it into the patients records. I would add, most likely it would have been recorded in the nursing notes as this provides a more pastoral account of the patient’s stay (as I’ve already explained).
With regards to whether it should have been recorded or not? I don’t know. When do we draw the line? Should we just take a camera in with us to record any interaction with patients, family, friends, whoever, along with a dictaphone and a solicitor? When do we allow “covering our backsides” get in the way of treating the patient, when do we become more legally expert in our field than medically expert or pastorally expert? We don’t have access to a glass ball, we don’t know what is coming down the line, we can guess and we can speculate but we can still, even with all the knowledge in the world, be wrong, and as long as humans are involved, this will always happen, whether we like it or not.
As regards recording in the medical records, as I have already said, it really is not the be all and end all – interviews must be carried out with staff who interacted with this patient, and it must be done sooner rather than later (I would hazard a guess that staff have already submitted written statements, so that minute details are not forgotten, but that’s a guess). As I say, and keep saying, clarification is the absolute least that must take place in this area, as this will remove most of the issues that we are discussing here.

@james. Really don’t see how you can equate writing down one statement stating that the patient requested a termination with carrying around a dictaphone and a solicitor to record conversations.
Having said that I do appreciate that medics are at times faced with legal difficulties particularly in relation to abortion in this country ( which is why I would have thought that it should be recorded for the sake of both medic and patient).
If it is genuinely the case that hospital policy would not record such requests (when the request is not carried out) hopefully new guidelines ( which mr reilly says are coming) will dictate that full and proper records are kept which includes termination requests ( for the sake of both patient and medic). I do take your point that records are not the be all and end all, but they are important nonetheless.
For instance if there was a situation where a consultant advised a patient that she should have a termination ( due to her life being at risk) and the patient refused a termination for e.g. religious reasons, then the termination would not take place. Unless i have picked you up completely wrong, according to your posts, recording of such medical advice and patient refusal of same would not happen because the ‘action’ was not carried out. This, to me, leaves the medic in a very vulnerable position.

Hi Irene, As Katie said earlier, do we record every little thing, no matter how daft it might be? For example as Katie said, it’s unlikely that a request to “kill her now” would have made it into the notes. What happens though if Katie gets into difficulty with delivery and passes away, and due to the fact that the staff did not forsake the life of Katie, the baby does not make it either? However had the staff acted sooner, and the mother passed away, would they have saved the life of the baby? It brings a whole new meaning to a flippant remark. (I’m not saying that Ms Halappanavar made the request flippantly, nobody does).
In the case of recommending treatments, if a doctor recommends a treatment he does so having weighed up the options, weighed up the outcomes, he makes an informed recommendation based on the situation presented, and he doesn’t do so flippantly or off the cuff. If a recommendation for treatment is made it will always be recorded in the notes, and the outcome of that recommendation will always be recorded clearly beside the recording.
My equation to having Dictaphones, camera recordings, solicitors present in interactions with patients and families was a reference to the question: how far do we have to go as doctors or nurses or midwives to protect ourselves?

@pajo. You provide a nonsense argument for why Praveen halappanavar should just ‘put up and shut up’, as you so kindly put it. The fact that other people have died whist in hospital care and such deaths may or may not have been thoroughly investigated does not take away from this man’s position of wanting an independent inquiry to bring to light what happened his wife. Many wrongs do not make a right.

Yeh the ones where she made the request for the termination and t was refused a couple of times. Wonder are the notes actually missing or were they ever made in the first place?!

Most likely the records are not missing, the request for termination was never recorded – see my comment under Katie Does! Hope that helps!

Makes sense to me James Connolly. Thanks for the insight.

@ James. Perhaps it is best not to pre-empt the results of ( hopefully) an independent inquiry, which will ascertain whether a repeated request for termination of a woman who was miscarrying her child was recorded or not.