THE HSE REPORT into the death of Savita Halapanavar has found that “inadequate assessment and monitoring” was a contributory factor in her death, and calls for greater clarity on the options available to doctors handling such cases.

The investigation was commissioned following the death of the Indian-born dentist at Galway University Hospital last October to establish the facts of what happened, and any shortcomings in the care she received.

The case made headlines worldwide after Savita was said to have been denied an abortion by doctors, despite requesting one. The 108-page document published this afternoon identifies key causal factors leading to her death, and makes a number of recommendations.

The report says that closer monitoring of the 31-year-old’s condition would have enabled the clinical team to recognise and respond to signs that the patient’s condition was deteriorating due to infection. It finds:

The risk of infection and sepsis increased with time following admission and especially following the spontaneous rupture of the patient’s membranes.

It said there was a “failure to offer all management options” to a patient experiencing “inevitable miscarriage”, adding that there was also evidence of:

Non adherence to clinical guidelines related to the prompt and effective management of sepsis, severe sepsis and septic shock when it was diagnosed.

Chronology

The report states that Savita – who was 17 weeks pregnant – was referred to the gynaecology ward of GUH on 21 October (accompanied by her husband) complaining of lower backache “radiating to the lower pelvic region”.

In the medical records, the diagnosis noted was that of an “inevitable/impending pregnancy loss”.  Savita was then admitted to the hospital for management of “inevitable miscarriage”.

The patient’s “membranes spontaneously ruptured at 00.30hrs on Monday October 22″. Her condition deteriorated on the 24 October and a diagnosis of ‘sepsis secondary to chorioamnionitis’ was made.

Savita was admitted to the High Dependency Unit (HDU) from the gynaecology ward at 16.45 on the 24th, the report says, at which point she was ‘post-miscarriage’

Her condition continued to decline, and she was transferred to the Intensive Care Unit (ICU) at 03:30 on the 25th, where she received ‘appropriate management’.

Her treatment continued, but the report states that she “she sadly passed away at 01.09 hrs on Sunday, the 28th of October 2012″.

Termination

The report records that Savita and Praveen Halappanavar had requested a medical termination at around 8.20am on the Tuesday before she died, and were met with the following response:

(The consultant) stated that the patient and her husband were advised of Irish law in relation to this. At interview the consultant stated“Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a foetal heart (sic)”.
The consultant stated that if risk to the mother was to increase a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection “we can’t predict who is going to get an infection”

Recommendations

The report makes a number of recommendations aimed at minimising the risk of such a case happening again, including:

• The prompt introduction of a “Maternity Early Warning Scoring Systems Chart” for patients receiving care for pregnancy complications which would define a coupled process of monitoring and response procedures.
• Mandatory education of all clinical staff working in obstetrics and gynaecology on the early recognition, monitoring and management of infection, sepsis, severe sepsis, and septic shock.
• The HSE should develop and implement “national guidelines on infection and pregnancy”, with a particular focus on “who is responsible for following up, reviewing and acting upon the results of tests ordered”.
• Guidelines on the “management of early second trimester inevitable miscarriage” that are cognisant of the “possible rapid deterioration of the patient from sepsis to severe sepsis to septic shock” which “could be within a few hours”. These guidelines must also “be cognisant of the high mortality rate (up to 60%) associated with this”.

Recommendation 4b states the need for greater clarity on the options available to doctors managing such cases, and says medical staff working in circumstances of “rapid deterioration or emergency” need more guidance “as to how to exercise their clinical professional judgement in a particular case”. It calls for the medical community and the Oireachtas to:

…consider the law including any necessary constitutional change and related administrative, legal and clinical guidelines in relation to the management of inevitable miscarriage in the early second trimester of a pregnancy.

It says the guidelines should include good practice rules in relation to “expediting delivery for clinical reasons” including “medical and
surgical termination based on available expertise and feasibility consistent with the law”.

In full: The HSE report into the death of Savita Halappanavar>

Savita report ‘hard-hitting, straight and doesn’t pull any punches’>

Timeline: A death that shocked a family, a hospital and a country>

Savita inquest: The coroner’s nine recommendations endorsed by the jury>