TANIA MCCABE WAS six months pregnant when she was admitted to Our Lady of Lourdes Hospital, Drogheda in March 2007.
Her waters broke prematurely but she was discharged from the maternity unit the next day. She was readmitted to the hospital less than 24 hours later.
Her twin boys, Zach and Adam, were born by caesarean section that night. However, Zach had severe congenital abnormalities and soon died in his mother’s arms.
The 34-year-old, who was a garda sergeant, then suffered a post-partum haemorrhage. Despite emergency surgery, she died at the hospital after going into septic shock.
A later High Court action claimed negligence on the part of the hospital and obstetrician because they had failed to diagnose that her waters had broken, wrongfully discharged her and did not recognise septic shock on readmittance.
In the third damning report into the death of Savita Halappanavar in Galway last year, the Health Information and Quality Authority (HIQA) found that very little had been learned from the tragic events.
“The findings of this investigation clearly show that where responsibility for implementation of learning is not clearly owned, then learning does not happen,” HIQA’s Phelim Quinn said.
This is demonstrated in the findings relating to the HSE inquiry into the death of Tania McCabe and her son Zach in 2007, the circumstances of which have a disturbing resemblance to the case of Savita Halappanavar.
The similarities between the two cases was “probably one of the most disturbing findings” of the probe, the Director of Regulation told reporters yesterday during a briefing.
As part of the investigation into the death of Savita Halappanavar, HIQA requested the HSE to provide details of how the recommendations of the report into the circumstances of the 2007 deaths had been implemented at each of the 19 public maternity units.
Of the 19, only five provided a details status update for all 27 recommendations of that report. They were the Midland Regional Hospital Mullingar, Coombe Women’s and Children’s Hospital, the Rotunda, Our Lady of Lourdes Drogheda and the Mid-Western Regional Maternity Hospital.
Of the remaining 14 – including University Hospital Galway – six reported their status against a different investigation or gave no comment. A number of the six reported that evidence for implementation was not in existence.
“This is unsatisfactory and concerning,” said the report, while Quinn described it as “unacceptable”.
“Both senior managers within every maternity hospital in Ireland, and the corporate HSE, are responsible for implementing this fundamentally important learning and should be held to account in doing so,” he continued.
Adam McCabe and his father Aidan ,widow of the late Garda Tania McCabe, looking at the Giraffe Omnibed Incubators donated by the McCabe Foundation to Holles St Hospital at a function in Garda Headquarters, Dublin last year.
One of the recommendations asked the HSE to adopt the international Surviving Sepsis Campaign to build awareness, encourage early recognition and standardise treatments.
The responses from hospitals across the country indicated a regionalised rather than national approach to the recommendations.
This lack of a coordinated approach raises a “fundamental and worrying deficit in our health system” again, said HIQA.
“Namely the ability to implement and apply system-wide learning from adverse events across the system in a timely and appropriate manner in order to prevent the recurrence of patient safety events that may cause harm, or worse, to future patients.”
Although HIQA does not have enforcement powers, Quinn said the 34 recommendations of the report into the treatment of Savita Halappanavar will have to be implemented satisfactorily.
“At the minute, we have very limited information to get any level of assurance,” he said. “There is a very significant emphasis on the requirement, firstly for local recommendations to be implemented in Galway, but they also need to be taken on board in other hospitals across the country.
“We have been having ongoing dialogue with the HSE…I think our recommendations do constitute a significant reminder to the HSE.
I don’t think the Irish healthcare can afford to keep missing these opportunities to get things right.
CEO of HIQA, Dr Tracey Cooper, added that the principals of yesterday’s report also relate to other non-maternity services and noted a recommendation that every healthcare provider self-assess their guidelines and protocols against the report’s findings.
The report found that there were 13 clear opportunities to intervene in the care of the 31-year-old dentist which could have changed the outcome of her treatment last year.
It concluded that there was “a failure in the provision of the most basic elements of patient care to Savita Halappanavar and also the failure to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner”.
The hospital has since apologised to Praveen Halappanavar and family for the care Savita received in October 2012.