Unavoidable tragedy – or unnecessary death?
Q: Did Savita die needlessly? Could she have been saved?
A: It's the question her grieving husband Praveen hoped the inquest into her death would go some way towards answering.
The testimony has been excruciating. Much has been laid bare and, while it is still not possible to say if Savita would have survived, it is clear she was dangerously let down and that her chances were drastically diminished by poor practices in the maternity unit.
Q: How ill was Savita when she was admitted to hospital?
A: She was admitted at 17 weeks pregnant. She was suffering from back pain and was told the prognosis for the foetus was poor but not non-existent. She was put on antibiotics as a precaution against infection.
Q: It all seemed to go wrong from there – why?
A: On the Sunday she was admitted, the first blood test was carried out. It had an elevated white-cell count reading, an indicator of possible blood poisoning. But it was not reviewed until 5.24pm on Monday by an unidentified member of staff. The results were not noted until Wednesday morning, when Savita was very ill. The timeline only emerged yesterday.
Q: Savita asked for a termination on Tuesday – should it have been granted?
A: The medical team at that stage were unaware of how sick Savita was. She appeared well. She was advised that a termination was not possible because the foetus still had a heartbeat and so the procedure would not be lawful. Midwife Ann Maria Burke admitted telling her Ireland was "a Catholic country" by way of explaining the law.
Q: What cardinal errors were made by staff?
A: Savita was seen by several doctors and nurses. From Sunday until Wednesday, different warning signs emerged but were not followed up and not shared among the staff. Savita should have been checked overnight every four hours for vital signs but she was not.
Staff were not properly passing on information to each other. The senior consultant, Dr Katherine Astbury, who checked Savita early on Wednesday morning, did not read Savita's medical notes and was not told of a discharge documented by another doctor overnight. He suspected infection and ordered stronger antibiotics.
Q: When Savita deteriorated early on Wednesday, how quickly did staff react?
A: Sepsis was diagnosed and a second blood test was ordered at 8.29am and reviewed by 10.30am. There was another mix-up due to a wrong bottle for a more detailed test which could have confirmed sepsis. Savita was given antibiotics on Wednesday morning, but they were ineffective.
Q: Should an abortion not have happened early on that day?
A: More tests were carried out to rule out a urinary infection. It was not until lunchtime that Dr Astbury decided to carry out a termination. A scan showed the foetal heartbeat had stopped. Savita was taken to theatre at 3.15pm to have an IV line inserted for antibiotics and she spontaneously delivered. She was taken to the high-dependency unit at 4.45pm and in the early hours of the morning she was moved to intensive care.
Q: What were Savita's chances at that point?
A: She was getting powerful antibiotics to counter her rare Ecoli infection. But Savita was in septic shock. She deteriorated further the next day and in the early hours of Sunday morning she died of a cardiac arrest.