Clinical review finds nursing staff failed to adequately assess and monitor Savita
NURSING staff failed to adequately assess and monitor Savita Halappanavar as a fatal infection took over her body, the review into her death has found.
The clinical inquiry into the death of 31-year-old dentist found the most likely cause of her inevitable miscarriage was infection, with the risk of that infection and sepsis increasing after her waters broke.
Mrs Halappanavar died on October 28 at Galway University Hospital, a week after being admitted.
She suffered multiple organ failure from septic shock four days after she miscarried a dead foetus.
Her widower Praveen, who is out of the country, has maintained that she repeatedly requested a termination but was refused because a foetal heartbeat was present.
World-renowned professor of obstetrics and gynaecology Sir Sabaratnam Arulkumaran headed the review on behalf of the Health Service Executive.
Dr Arulkumaran said the Halappanavars had inquired about the possibility of having a termination but that this was not offered or considered possible by the clinical team until the afternoon of Wednesday October 24 because of legal constraints.
The chairman said the plan was to "await events", which he said is appropriate provided it is not a risk to the mother or foetus.
"Appropriate monitoring and evaluation of the changing clinical presentation with appropriate clinical investigations would likely have led to reconsideration of the need to expedite delivery," he said.
"Monitoring and adherence to guidelines for the prompt and effective management of sepsis would likely have helped to prevent rapid deterioration of the patient.
"Delaying adequate treatment including expediting delivery in a clinical situation where there is prolonged rupture of the membranes and increasing risk to the mother can, on occasion, be fatal."
Mrs Halappanavar's waters broke in the early hours of Monday morning and her condition deteriorated in the early hours of Wednesday morning.
The long-awaited report was published two months after an inquest jury ruled unanimously that Mrs Halappanavar's death was by medical misadventure.
The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar's care before she died, but coroner Ciaran MacLoughlin said they did not contribute to her death.