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A catalogue of systems failures

A breakdown of the final week of Savita Halappanavar's life:

 

Sunday October 21

2pm: Savita, below, is admitted to University College Hospital Galway with a suspected miscarriage. Blood tests indicate possible infection but the results are not collected. Monday October 22

12.30am: Savita's membranes rupture.

8.30am: Scan shows foetus is still alive. Savita put on antibiotics to "lessen risk of infection".

Tuesday October 23

8.30am: Savita asks for foetus to be induced. Dr Katherine Astbury tells her law does not permit it while foetal heartbeat is there.

7pm: Savita's pulse rate elevated at 114. Midwife says she told on-call doctor about elevated pulse. He says he was only told she was weakening.

9pm: Savita's pulse rate is lower. It is not checked again for more than nine hours, in breach of hospital guidelines.

Wednesday October 24

1am: On-call doctor checks on Savita but she is asleep. He does not examine her.

4.15am: Midwife gives shivering Savita an extra blanket, paracetemol for a temperature but doesn't take her pulse.

6.30am: Savita's pulse is 160, she is running a fever and has a foul-smelling discharge. On-call doctor diagnoses sepsis, pinpointing probable source as her ruptured membranes.

7am: Blood samples taken but they don't reach the laboratory until after 10am. A lactate test – a key test for sepsis – sent back because it was mistakenly sent.

8.35am: Dr Astbury, left, reviews Savita, diagnoses sepsis, and awaits further tests. She tells Savita she may have to terminate. But, crucially, she is unaware of foul discharge. Her registrar, Dr Ann Helps, says she wasn't told, and she didn't read it in the notes.

1pm: Savita's condition deteriorates; her consultant seeks a second opinion before deciding to terminate. A scan reveals the foetus is dead.

3.15pm: Savita is admitted to theatre. While a central line is being inserted, she spontaneously delivers a baby girl they call Prasa.

4.15pm: Savita is transferred to high-dependency unit.

Thursday October 25

3am: Her condition deteriorates and she is transferred to intensive care.

Friday

October 26

10am: Savita is critically ill as test results show septicaemia caused by ecoli ESBL.

8pm: Dr Astbury calls to see her patient. .

Saturday October 27

Friends call to Savita and rally around Praveen, below.

Sunday October 28

12.45am: Savita suffers a cardiac arrest. Praveen is present as doctors try to resuscitate her. She does not respond.

1.09pm: Savita dies.

Irish Independent