Wednesday 22 May 2019

Savita doctor – law was factor in termination decision

By Caroline Crawford

THE DOCTOR who treated Savita Halappanavar said she was unable to offer Ms Halappanavar a termination because her health was not in any danger and she feared it could become a legal issue.

Dr Katherine Astbury, consultant obstetrician at University Hospital Galway told the inquest she had not seen Ms Halappanavar's blood results when she first examined her and was unaware of the change in her blood count. She conceded that such a change "can be indicative of severe sepsis".

"Obviously if we had had the blood results back at that stage we may have considered intervening sooner," she said.

It also emerged that there were longer than four hour gaps for checking Ms Halappanavar's vital signs at night. The 31-year-old's condition deteriorated overnight. Dr Astbury accepted that these delays were a "system failure" when it was put to her by Dr McLoughlin.

When asked why she had approached a second member of staff to discuss carrying out a termination, Dr Astbury said she considered it good practice if going to do something out of the ordinary that you would seek the opinion of a second senior member of staff.

When asked by the coroner, "Did you think it might be a question of law?" Dr Astbury replied; "Yes."

Dr Katherine Astbury pictured arriving at Galway Courthouse before the start of the third day of the inquest in to the death of Savita Halappanavar
Dr Katherine Astbury pictured arriving at Galway Courthouse before the start of the third day of the inquest in to the death of Savita Halappanavar
Savita’s husband Praveen with his solicitor outside Galway Courthouse
Praveen Halappanavar with his late wife Savita
Savita Halappanavar. Photo: Reuters

She said later she felt inhibited and constrained by the legal laws in Ireland when it came to Savita's case.


The consultant said the termination as requested by Ms Halappanavar was not legal.


Speaking about Ms Halappanavar's condition on the Tuesday, after the young woman had requested a termination, Dr Astbury described her patient as being "emotionally distressed". When asked if emotional distress was as far as it went, she replied, "Yes, She's not physically unwell."


Dr Astbury again defended her decision to hold off on any possible termination, stating; "I am waiting because the law states in the absence of risk to the life of the mother there is no reason to intervene."


Speaking about her interaction with Ms Halappanavar Dr Astbury said her patient had been discussing how upsetting it was that the miscarriage had not occurred but she had no hopes of the baby surviving.


"She was finding it very upsetting and difficult to have to sit with the baby in her knowing that the ultimate outcome was that she was very unlikely to come out with a live baby.


"I said to her in this country it was not legal to terminate pregnancy on the grounds of poor prognosis for the foetus," she said.

Dr Astbury earlier also accepted that she wasn't aware that the white cell count had risen to 16.9.

"If I had known that, yes I would have rechecked it," she said.

The consultant said that as the results had not been documented, she had no reason to believe there was an abnormality and so assumed it was normal.

Conceeding that this also represented a system failure, Dr Astbury said; "I suppose each team should also check their own results."

This point was then stressed by the coroner who said there had been "two system failures" in that the patient was not monitored in four hourly visits after the spontaneous rupture and secondly that the blood count was not related to Dr Astbury.


Later coroner, Dr McLaughlin questioned the "confusion" of the notes which contained a high number of notes put on retrospectively.


"I've seen numerous notes and I've never seen so many retrospective notes," said coroner Dr McLaughlin.


Mr Gleeson, counsel for Praveen Halappanavar, said in his 33 years of practice he had never seen notes like these, saying the system in Galway was "inviting confusion".


Dr Astbury said the large number was as a result of staff working for several consultants on a ward at the one time.


Asking if that could be changed, Dr McLaughlin added: "Can't you see how it could cause a failure - and we are trying to prevent system failures". He added that he would be concerned about putting in notes two weeks after the event.


Earlier the inquest heard that Dr Astbury had planned to give Ms Halappanavar the drug Misoprostol, a drug to bring about induced labour on the Wednesday afternoon.


She said this could have taken up to 24 hours to work.


"It usually takes several hours, eight or nine or ten would not be unusual," said Dr Astbury.


Dr Astbury discussed performing a termination with clinical director Geraldine Gaffney, who agreed with her view.


However, a final scan was carried out and found no feotal heartbeat.


Dr Astbury insisted she had informed the couple that there was no feotal heartbeat at 1.45pm. This was at odds with evidence from Praveen Halappanavar who said they had not been told of the baby's death.


Dr Astbury then spoke to colleagues in order to have Ms Halappanavar assessed for High Dependency Admission. Prior to this the consultant made steps to transfer Ms Halappanavar to theatre to insert a central line.


Brought into theatre at 3.15pm. She delivered the feotus of her baby daughter Prasa at 3.45pm. An hour later, Savita was moved to HDU and was transferred to the ICU at 3am when she deteriorated further.


Further ultra-sound and CT scans were done to ensure there were no residual products of conception left in the uterus as the infection continued to worsen. Savita  deteriorated over the day and needed extremely high levels of medication to regulate her blood pressure, Dr Astbury told the inquest.


Referring to her discussion with Praveen Halappanavar when his wife was seriously ill, Dr Astbury said Praveen had asked whether the infection was related to fact that Savita's waters had broken days earlier.


Dr Astbury said she told Mr Halappanavar that while it could be related to the ruptured membrane, that three days was not a significantly long time. She went on to give the example of a woman whose membrane went at 19 weeks who ultimately delivered at 32 weeks.

Dr Astbury worked at the Galway hospital from May 2011, she had previously been a locus in St James and the Coombe since May 209, the inquest was told.

The consultant said that when she reviewed the records of Ms Halappanavar's first attendance, she had not attached any significance to Ms Halappanavar's frequent need to urinate or the back pain.

While she said that back pain was a common problem in pregnancy and Ms Halappanavar had a pre-existing issue with back pain, Dr Astbury conceded that it could have been contractions at that stage.

Dr Astbury told the inquest that had she delivered at the stage when the membranes had ruptured there was no prospect of the baby's survival.

She told the inquest she did not agree with the view of her colleague who has said the pregnancy loss was "inevitable" when he reviewed her. Dr Astbury insisted there was a "very small prospect" of the pregnancy remaining viable.

"If the membrane ruptures under 20 weeks there is a 12 to 18pc chance of the foetus reaching viability," she said.

Dr Astbury yesterday read her statement to the court in which she revealed how she planned to go ahead with a termination just hours before Savita eventually miscarried.

Dr Astbury had finally decided to carry out a termination regardless of foetal heartbeat on Wednesday, October 24, 2012. Just one day earlier on Tuesday she had refused Ms Halappanavar's request for a termination, despite informing her that a miscarriage was inevitable.

Savita Halappanavar (31) died on October 28 last at Galway University Hospital. She was 17 weeks pregnant when she was admitted to the hospital a week earlier suffering a miscarriage.

It also emerged that the insertion of a bracket which was noted on the medical notes of Savita Halappanavar was not done by the HSE review team probing her death.

Declan Buckley, Senior Counsel for HSE said the notes have been in a safe from November 14 and had been under the safe keeping of  Tony Canavan, chief operating officer of the Galway Roscommon hospital group from that period.

Mr Buckley said the bracket, which was squiggled down on side of notes bracketing a number of entries together, and originally taken by midwife Miriam Dunleavy may have been done by a member of the medical during her time in the ICU who was reviewing her care up to that date.

"The only explanation is that somebody who was reviewing the chart and shouldn't have done it, I'm not standing over it. Took a pen and simply marked those four areas," he said.

"The content of the notes has not been altered or added to save for that bracket being placed," he added.

This was accepted by the coroner but he pointed out that somebody had still emphasized those particular notes.


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