ALTHOUGH the inquest into the death of Savita Halappanavar was never tasked with apportioning blame, it hovered persistently throughout eight days of hearings.
When her husband's legal team went down a line of questioning that might suggest blame, Declan Buckley, the barrister for the Galway hospital where she died, was on his feet shooing it away. It refused to go away, and on Friday morning it came right into the council chamber where the last days of the inquest sat.
Thirty-six hospital staff and expert witnesses had testified over seven days. The coroner, Dr Ciaran McLoughlin, was about to present his summing up. The jury was about to be asked to reach its verdict. Eugene Gleeson, the barrister for the dead dentist's husband, Praveen, asked to make a submission in the absence of the jury of six men and five women, mostly middle-aged.
He began emotionally. He told the coroner how Praveen goes back at night to a cold home where once there was love, how his "large and deeply intelligent eyes had seen unbearable sadness", and how he "is determined that some person or persons will be held accountable" for what happened to her during her first three critical days in the care of University College Hospital Galway when the infection that killed her was overlooked.
If the coroner was going to make any recommendations as a result of what happened to Savita, could it be done "as strongly and as clearly as the English language will allow and as close to accountability as Irish law will permit." Lawyers for the hospital and the consultant rejected that submission.
Declan Buckley argued that to censure staff would be unbalanced and unjustified.
The inquest had heard evidence from an expert witness that the only thing that could have saved Savita was a termination within a day or two of being admitted to hospital, and by the time it was lawful to perform a termination, she was beyond saving.
"An extremely rare condition had been dealt with as best as possible by hospital staff on duty," he said, referring to the blood poisoning caused by E.coli that ravaged through her with frightening speed, causing her death by multi-organ failure.
Barrister Eileen Barrington said there was "no basis in fact or law" to call for the accountability of her client, Dr Katherine Astbury, the consultant responsible for Savita's care while in hospital.
Everyone had done their best. No one could be reproached, as was frequently pointed out an inquest is not allowed to point fingers; that is for the civil and criminal courts.
The jury returned, listened to the coroner's grim summation of her journey towards death – at one point, he became emotional when he mentioned the critical point at which her life was in peril.
They returned with the closest verdict they could give in terms of suggesting where the responsibility lay.
Death by medical misadventure and their "strong endorsement" of each of the coroner's nine recommendations addressing the many systems failures and deficiencies in the care given to Savita Halappanavar at University College Hospital Galway on October 28 last year.
Afterwards, lest the verdict be misconstrued, Declan Buckley asked the coroner to point out that the "systems failures and deficiencies" had not caused or contributed to her death.
So where does this leave Praveen Halappanavar, the 33-year-old biochemist with Boston Scientific, prematurely widowed, supported by friends but ultimately alone, comforting himself with the presence of his dead wife?
At the outset of the inquest, he said he hoped it would provide answers. After the verdict on Friday, he indicated that he didn't get them.
"Somebody has to take the ownership of a patient when they walk into a hospital," he said in a short press conference afterwards.
The chronicle of Savita's care, punctuated by miscommunications, clashing recollections, oversights and inadequate treatments, was told over six days at the inquest.
How she was admitted to UCHG on Sunday, October 21, and found to be miscarrying; how after her membranes ruptured, leaving her open to infection; how she pleaded for a termination, but her consultant, Dr Katherine Astbury, explained that the law prohibited a termination unless there was a risk to her life; how as the signs of infection developed she was given a paracetamol and a blanket; how she was diagnosed with sepsis two hours later; how her consultant, Dr Katherine Astbury, was not informed of a key symptom of a malodorous discharge that would have prompted her to remove the foetus earlier, and unaware of that information, she decided to await further tests, by which time Savita was in septic shock.
Throughout, there were stories of delayed and overlooked blood tests results, symptoms missed, doctors missing vital symptoms in her patient notes, and even at a key period in her illness, inadequate antibiotics administered, incorrectly labelled samples, and plummeting blood-pressure readings over two hours that were never communicated to a doctor.
The involvement of the high-dependency and intensive care teams from later that afternoon and until her death was never in question.
The questions whirling around in Praveen Halappanavar's brain all revolve around the first three days of her care. The hospital staff who cared for her during that time gave their evidence over six days.
The first independent appraisal of their evidence came on Wednesday, when the inquest's expert witness, Peter Boylan, former Master of the National Maternity Hospital which was one of the hospitals where Savita's consultant, Dr Katherine Astbury, had trained.
Mr Boylan, who sits on the Government's expert committee on abortion, said he didn't know Dr Astbury.
His medical report, which he read to the inquest, didn't suggest any shortcomings in Dr Astbury's treatment of her patient, but he did identify six "deficiencies" in Savita's care.
Dr Olutoyele Olatunbosun, the senior house officer in gynaecology, who treated Savita when she first presented to UCHG on Sunday, October 21, took a blood test but only to check her blood type, and passed over the other significant finding that Savita had an elevated white cell count, indicating that she was fighting an infection.
According to Dr Boylan, the failure to note the elevated white cell count in the chart was a "deficiency" in Savita's care. Questioned at the inquest, he said that the blood test should have been repeated. But even it if it had, he thought it unlikely that it would have had "any material impact on the eventual outcome".
Dr Ikechukwu Uzockwu, and the midwife, Ann Maria Burke, gave conflicting accounts of a telephone conversation on the night of Tuesday, October 23, when Savita began to display the first signs that she was developing sepsis. So much so, they were recalled by the coroner on Wednesday – but each stuck to their irreconcilable versions.
That evening, a student midwife reported to the midwife manager, Ann Maria Burke, that Savita's pulse was elevated, at 114 beats per minute. Ms Burke asked her to recheck it and it was still high at 110. The condition is called tachycardia, which the coroner noted on several occasions is one of the signs of sepsis.
Ms Burke said she rang Dr Uzockwu at 7.35pm and told him that Savita had an elevated pulse rate, and asked about giving her a bath.
Dr Uzockwu was the senior house officer on duty that night. But Dr Uzockwu said he was never told about her elevated pulse rate, just that she was "weakening".
So he continued seeing his other patients on the busy ward and didn't get around to seeing Savita until 1am.
By then, she was asleep, so he didn't wake her, nor did he check her chart hanging on the end of her bed, which would have shown her high pulse rate earlier.
Mr Boylan said Dr Uzockwu's decision not to wake her was "reasonable" but he included the conflict of evidence in his list of deficiencies.
When at around 4.30 that morning Savita started shivering, her teeth were chattering. Midwife Miriam Dunleavy fetched extra blankets because the room was cold. She took her temperature, which at 37.9 degrees indicated a fever, but took what she called a "clinical decision" not to take her pulse. She too was busy, tending to 15 patients with one other nurse on duty, Nurse Gallagher.
In his medical report, Peter Boylan suggested that if she had taken her pulse, it was likely that it would have increased, prompting the nurse to ask a doctor to review her. That in turn would likely have led to a suspicion of infection and a "septic work-up" from 4.30am rather than 6.30am, when sepsis was first diagnosed.
But Savita's pulse wasn't taken at 4am, and a doctor wasn't called. "It is a pity she didn't take her pulse," he told the inquest. "If she [a patient] has a slightly elevated temperature, best practice is to find a cause for it before giving them paracetamol," he said. "In retrospect, it was probably an error of judgement."
Even if she had, Mr Boylan suggested, the outcome wouldn't have been much different. The antibiotics Savita would have received – the same ones she later received at 6.30am – were unable to fight the organism that would kill her. On the balance of probabilities, he said her she would still have developed a fever at 6.30am, which is when doctors first diagnosed her sepsis.
By then, Dr Uzockwu had diagnosed sepsis – suspected chorioamnionitis – an inflammation of her ruptured foetal membranes. He set her up on a drip and the obstetrics staff administered antibiotics, according to international guidelines. Another expert witness, Dr Susan Knowles, found that antibiotic treatment that morning was inadequate and did not follow hospital guidelines on sepsis management.
Mr Boylan told the inquest that if Savita had been in the National Maternity Hospital, she would have been treated with a triple regime of antibiotics that would have been more effective in fighting the microbe that killed her.
Mr Boylan made no criticism of Dr Astbury, Savita's consultant. According to his assessment, the biggest factor affecting her treatment of Savita was beyond her control. In his medical report, Mr Boylan said: "The real problem was the inability to terminate the pregnancy, prior to Ms Halappanavar developing a real and substantial risk of death. By that time, it was effectively too late to save her life."
Had this been done on the Monday or Tuesday, he said it was highly likely that Savita would be alive. But Dr Astbury, like other doctors, was hampered by the law, which prohibits termination unless there is a real risk to the mother's life.
By the time Dr Astbury viewed her patient again at 8.25am on her ward round on Wednesday morning, Dr Astbury was ready to terminate, recognising that sepsis put Savita's life at risk.
But Mr Boylan also noted that "due to the legal situation, however, the presence of a foetal heart at this time had an influence on that decision".
According to Mr Boylan, her decision to wait for the results of blood tests to see if there were other sources of infection, before going ahead with a termination, was "reasonable". But Dr Astbury wasn't fully appraised of all the facts.
Although Mr Boylan didn't address this in his report, Dr Astbury was not told of a key symptom of sepsis – a foul-smelling discharge – because her registrar carried the medical charts and it was her job to inform her.
Nor was Dr Astbury aware of Savita's deteriorating condition after she left to see her other patients on Wednesday morning.
Savita's blood pressure plummeted between 8.50am when it was 110/65 to 1pm when it had dropped to 73/100. The downward spiral of the readings was rapid and alarming. The nurse who took the readings recorded them in Savita's observation chart, but made no notes. A doctor should have been called but wasn't.
When the investigations into Savita's death began, the nurse, who has not been named, presented the coroner with a medical certificate, indicating that she was not in a position to make a statement.
According to Mr Boylan, the absence of her statement led to one of the most serious decifiencies in understanding what happened to Savita. But the coroner said: "The nurse is the only witness not to have given a statement and no statement will be forthcoming and there is nothing we can do about that."
According to Dr Boylan's assessment, Savita's death had a certain inevitability about it – even without the catalogue of deficiencies that dogged her treatment.
Dr Peter Kelehan, a retired pathologist, testified as to the speed of an infection so rare that he had seen five cases in 40 years, and none of those patients died.
Had Dr Uzockwu woken her to take her pulse at 1am, had Midwife Dunleavy taken her pulse at 4.30am, and had her sepsis been diagnosed earlier, a decision to terminate her pregnancy and remove the source of infection would most likely not have happened until after she was seen by her consultant at 8.35am. The medication to terminate would have been administered by 9.30am with delivery of the dead foetus by noon at the earliest. By then she was already critically ill with an antibiotic resistant E.coli, and, on the balance of probabilities, would still have died.
But for every hour that she was not treated, her chances of mortality increased by six per cent.
In the coming weeks, the Health Service Executive – which has apologised for the lapses in Savita's care – will publish its clinical review of her treatment.
But Praveen Halappanavar can expect no individual accountability there either. It was a fact- gathering exercise, to establish the truth, and names won't be published.
Praveen Halappanavar has several options. He can make a complaint to the professional medical and nursing bodies, he can lodge a civil action, he can go to Europe and he can continue to campaign for a public inquiry. One thing he won't be doing is giving up.
"I haven't got my answers yet why Savita died. I do have responsibility. I mean Savita's parents, I owe it to them, I owe it to Savita. They want to know the truth so I will, I will get to the bottom of the truth and there is no way of looking back."