AN early warning system aimed at alerting staff to a deterioration in patients in maternity units will not be rolled out nationally for several months.
The introduction of this simple guide is among the key recommendations in the final draft report into the care of Savita Halappanavar (31) who progressed from sepsis to septic shock before dying in University College Hospital Galway last October.
Savita was 17 weeks pregnant and told she was miscarrying when admitted to the hospital. But a combination of events, including failure by staff to recognise and diagnose a life-threatening infection on time, led to her death.
The HSE told the Irish Independent yesterday that significant progress has been made in implementing this "early warning system" and a national standard has been agreed.
However the alert system – based on a series of readings and observations by staff – is still being piloted in hospitals, including Galway, and will not be rolled out nationally until the coming months. The final report confirms findings and conclusions in an earlier draft, published in the Irish Independent in February, showing the gravity of her condition was not grasped on time and she was was not properly investigated or monitored.
Gerard O' Donnell, solicitor for Savita's husband Praveen, said his client does not believe the report explained why his wife died and he wrote to the HSE seeking a meeting with the chairman of the inquiry, the UK obstetrician Prof Sir Sabaratnam Arulkumaran. It is understood that the meeting will take place this week.
There was an over-emphasis on the need not to intervene while there was a foetal heartbeat, although Savita was going to suffer an inevitable miscarriage.
The inquiry team found that Savita, who was admitted to hospital on Sunday October 2, was not diagnosed with probable sepsis until the Wednesday morning – but by lunch time she was found to have progressed to septic shock.
The report points to what appears to be a cautious approach by the medical team on the Wednesday when a possible termination was discussed.
The report notes the ruling of Judge Hugh O'Flaherty in the X case, which allows for abortion where there is a "real and substantial risk to the life of the mother".
The ruling states the patient does not need to be at the stage of imminent death.
A consultant caring for Savita said that: "If there is a threat to the mother's life you can terminate. If there is a potential major hazard to the mother's life the law was not clear . . . there are no guidelines for inevitable miscarriages."
Savita suffered a miscarriage at around 3.15pm on the Wednesday and was transferred to the high dependency unit before being placed in intensive care that night.
Praveen said both he and Savita had requested a termination on a number of occasions earlier on in the week but were refused. The report details just one of these requests.
Savita's care was also affected by serious lapses in communication between the medical team looking after her. This resulted in delays in follow-up crucial test results.