AN EXPERT witness has said Savita Halappanavar would have survived had she received a termination on Monday, October 22 or Tuesday, October 23. However, the legal situation in the country would have prevented this.
Dr Peter Boylan, the former Master of the National Maternity Hospital in Dublin, said he did not believe carrying out a termination on Ms Halappanavar from Wednesday onwards would have saved her life as her condition was too serious at that stage.
Dr Boylan said that while a much earlier termination would have saved her life, there was not a real and substantial risk to her life at that stage and therefore legally a termination could not be carried out.
Giving his expert opinion on the case today Dr Boylan said the real issue of the case was that legally a termination could not be carried out on the Monday or Tuesday.
"The real problem was inability to terminate the pregnancy prior to Ms Halappanavar developing a real and substantial risk to her life, by that stage it was too late to save her life," he said.
"Had Ms Halappanavar's pregnancy been terminated on Monday, October 22 or Tuesday, October 23 it is highly likely on the balance on probability that she would have survived. However, termination at that time was not a practical proposition because of the law," he said.
Dr Boylan added that while Ms Halappanavar was sick enough to justify legal terminiation in this country by Wednesday morning, he did not believe a termination at this stage would have saved her life.
Dr Boylan said that from 6.30 onwards she was seriously ill, enough to justify a termination. However, he said that any termination from 9.30am on Wednesday morning onwards was unlikely to make a difference to the outcome.
Dr Boylan also noted the lack of a statement from one midwife who cared for Ms Halappanavar on Wednesday, October 24 stating that such a statement would been "most helpful" in the case. Dr McLaughlin told the jury the nurse in question was the only person who hadn't given a statement and would not be giving a statement.
"She has certification and there is nothing we can do about it," he added.
Dr Boylan also pointed to a number of deficiencies in the care of Savita Halappanavar including a failure to record the initial white blood count or repeat the case. This and other failures led to a delay in treating Ms Halappanavar.
Dr Boylan said that there was a number of deficiencies in her care which on their own may not have had a serious impact but cumulatively had resulted in a delay in several hours in Ms Halappanavar's care. He revealed that each hour of delay increased the risk of mortality by 6pc.
This was later repeated by the coroner who said; "Every hour delay increases the risk by 6pc. There were seven hours so the risk was increased by 42pc."
Earlier the court heard how Savita’s full vital signs were not taken for a critical nine and a half hours in the run up to finally being diagnosed with sepsis.
The last full vital signs were recorded at 9pm on Tuesday, October 23. They were not taken in full again until 6am on Wednesday morning.
During that vital nine and a half hours, Ms Halappanavar's temperature was recorded twice but no other vital signs, pulse, respiratory rate, nor blood pressure, were taken
"We now know the full vital signs were not checked between 9pm and 6.30am the next morning," said Dr McLoughlin.
"I can only go with what I was told and I was told the vital signs were stable," replied Dr Ikechukwu Uzockwu Senior House Registrar who treated Ms Halappanavar from Tuesday night until Wednesday morning when he diagnosed chorioanmionitis, an infection of the membrane.
Dr Ike was one of two witnesses who was recalled to give evidence this morning after he and a midwife giving differing versions of events on the last evening before Savita was found to be seriously ill.
The inquest heard first this morning from Midwife Ann Maria Burke.
Dr McLaughlin asked her to confirm that the last paragraph of her statement which said she had called Dr Ike on the evening of Tuesday, October 23 to make him aware of an elevated pulse.
"I asked him if it was appropriate for the patient to have a bath, he said no. I also made him aware of the elevated pulse," she said.
Dr Ike has insisted he was told all of the vital signs were normal.
When questioned on the matter today, Ms Burke insisted on her version of events.
"I am 100pc certain that I told him what I said in the statement regarding the elevated pulse. I also discussed a bath," she said today.
Ms Burke recalled being told by a student midwife Finnucane of an elevated pulse which was raised to 114. She asked Ms Finnucane to recheck the pulse "because it was elevated and quite often when you ask for a recheck it can be normal," she said.
The second reading was 110, which continued to cause Ms Burke concern.
"I was concerned, that's why I mentioned it to the doctor," she said. She added that she believed she had contacted Dr Ike before 8pm.
Ms Burke said pulse rates were "frequently elevated" particularly on a maternity ward.
Dr Ike returned to the inquest today.
His statement was also re-read which stated that he was told that he was informed that the vital signs were in the normal range. He added that it was his recollection of the event that the phone call was between 9pm and 11pm.
Today he stood by his evidence adding that he could not recollect which midwife made the specific call.
Dr Ike agreed with Dr McLoughlin's summing up of the time frame after this phone call.
He did not get the opportunity to check on Ms Halappanavar until 1am on Wednesday morning. At 1am he arrived on ward but as Ms Halappanavar was asleep he did not examine her. He conceded he did not look at the patient's chart at that stage.
He was finally re-called to check on Ms Halappanavar at 6am on Wednesday at which stage he diagnosed Chorioamnionitis.
Dr Boylan said Ms Halappanavar had suffered a "rapid sequence" of sepsis leading to septic shock.
He told the court that the medical team treating Savita had to await the arrival of sepsis before intervening. Sepsis carries a 20pc to 40pc chance of death and as such can be considered "a reasonable risk to the mother", he said.
Dr Boylan stressed the difficulties faced by doctors working in Ireland when it came to the current legislation surrounding terminations here.
"Doctors who come to this country from abroad have great problems understanding the situation which we have to work in. They cannot understand the law but we have to work within the law," he said.
While earlier highlighting a number of deficiencies in the care of Savita Halappanavar he pointed to a failure to record the initial white blood count or repeat the case, confusing on measuring lactate, the poor quality of notes on Wednesday October 24 and the lack of a statement from the midwife caring for Ms Halappanavar on Wednesday.
Dr Boylan said Ms Halappanavar's condition had deteriorated by 4.15am on Wednesday morning when she complained about being cold and shivery.
He told the court that her condition merited a clinical review at this stage adding taht "things went seriously wrong" for Mrs Halappanavar between 5.15am and 6.30am as the infection spread.
Speaking about nurse Miriam Dunleavy's decision not to take Savita's pulse at 4.15am on Wednesday morning, when she found her to be shivery with her teeth chattering Dr Boylan said; "In retrospect it was probably an error of judgment".
Dr Boylan said that the best practice when treating someone with a raised temperature is to find the cause before administering paracetemol as this will subdue the temperature without finding the reasons behind it.
"It's a pity she didn't take her pulse," said Dr Boylan.
Dr Boylan agreed that while Ms Halappanavr had sepsis from the early hours of Wednesday morning, severe sepsis had only set in by 10.30am, two hours after Dr Astbury had carried out her ward rounds. He told the court he could not understand why a doctor was not alerted at 10.30am.
Dr Boylan agreed with Eileen Barrington, counsel for Dr Katherine Astbury, that there was a twofold test when it came to carrying out terminations in Ireland. That there must be a real and substantial risk to the life of mother and that that risk is only capable of being avoided by the termination.
The expert witness said he believed viability of the foetus would not occur in this case but said that every obstetrician had come across cases where women with ruptured membranes early in the pregnancy have gone on to deliver healthy babies.
"What is different here from everywhere else is that the woman has no input into her care here," he added.
The inquest heard that Savita's baby daughter had been developing perfectly and there was no obvious reason as to why the miscarriage had occurred.
Dr Michael Tan Chien Sheng consultant pathologist at UHG who performed the autopsy on baby Prasa told the inquest the baby was completely normal with the exception of a extra digit on the fifth finger of her right hand.
Coroner Dr McLaughlin told the jury that a miscarriage at this gestation can sometimes indicate that the baby was not compatible with life.
"A miscarriage at this gestation may indicated something wrong with the baby that is incompatible with life but so far as we can see there was nothing wrong with this baby," he said.
The pathologist said that while there was evidence of e-coli in two samples that did not necessarily mean the baby had been infected. He told the court he had seen no evidence to suggest an immune response to the bacteria.