The jury in the inquest into the death of Savita Halappanavar made nine recommendations to be applied nationally in a bid to protect patients from further failures in the Irish health care system.
The Medical Council should 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 (the Nursing Board) should have similar directives for midwives so the two professions always complement one another.
Blood samples should be properly followed up and proper procedures put in place to ensure errors do not occur.
Protocols should be followed in the management of sepsis and there should be proper training and guidelines for all medical and nursing personnel.
Proper and effective communication should occur between staff on-call and a team coming on duty and a dedicated handover time is to be set aside for such communications.
A protocol for sepsis should be written by the department of microbiology for each hospital and each hospital directorate.
A modified early warning score chart should be adopted by all hospitals as soon as possible.
Early and effective communications with patient and/or their relatives should ensure that a treatment plan is readily explained and understood.
Medical notes and nursing notes should be separate documents and kept separate.
And finally, no additions should be 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.