Shortcomings in care of Savita have ramifications for all State hospitals

AT the inquest into the death of Savita Halappanavar, facts collided and recollections clashed. There were reams of clinical evidence, medical terms most journalists couldn't spell, exchanges on whether it was probable or possible that one would die of septicaemia. But the tragedy was brought home by the nurses who cared for her in her final days.

She was fully aware of her surroundings when she was rushed into theatre three days before she died. Noreen Hannegan, a theatre nurse, held her hand and explained the procedures, trying to reassure her as best she could. She was uncomfortable while lying flat and had to turn her head to one side while doctors installed a central line to pump medication into her body. At one point, she mentioned that she felt pressure "down below". When they checked, they found that Savita had delivered her dead foetus.

Later, restless and agitated, she pushed away the oxygen mask over her face because she could no longer tolerate it. Nurse Aine Nic An Beatha helped her brush her teeth and wash her face, and told her she was sorry for the loss of her baby. Later again, Savita struggled to breathe and became anxious.

Even clinical readings of her pulse and blood pressure as her organs failed were imbued with haunting sadness by Jacinta Gately, a nurse in intensive care, who read a statement to the inquest chronicling Savita's last hours. She was sedated with morphine and on a ventilator, her body swollen, her abdomen distended, her fingers flexed tightly and her feet extended and stiff. The alarms went off. The consultants attempted CPR. Nurse Gately went out to Praveen to ask if he wanted to be present, which he did. Savita did not respond. "The time of death was recorded at 01.09 hours," Nurse Gately concluded, her delivery clear and unfaltering but unable to keep the emotion from her voice.

The story of Savita's death begins and ends at Galway University Hospital – from her admission to St Monica's maternity ward on Sunday, October 21 last year with a suspected miscarriage to her death of blood poisoning and E-Coli in intensive care seven days later. However, the inquest, which opened last Monday, has exposed frightening shortcomings in her care that have ramifications for all State hospitals.

The coroner, Dr Ciaran McLoughlin, identified a series of "systems failures" during Savita's first four days in hospital that caused her ultimately fatal infection to be missed.

On the morning of the day she was admitted – October 21– her husband, Praveen, brought her to Galway hospital. She was complaining of lower back pain. Dr Olutoyele Olatunbosun, a senior house officer in gynaecology, was on call in the obstetrics unit that day. As Savita had a history of back pain, she sent her home. Savita returned to hospital around 1pm, complaining of a sensation that something was pushing out of her.

Termination should not come down to percentages Michael McDowell, Back Page

Dr Olatunbosun found that her cervix was dilated and that the membrane surrounding the foetus was bulging into her uterus. She asked a specialist obstetrics registrar, Dr Andrew Gaolebale, who was senior to her, for a second opinion. He diagnosed an "inevitable pregnancy loss". His advice was to admit Savita and wait for the miscarriage to occur.

Dr Olatunbosun sent a blood sample to the lab to establish a "baseline", in case Savita needed blood following the miscarriage, but never followed up the results. Had she done so, she would have found that Savita had an elevated white cell count – an indicator that the body is fighting infection.

It was the first systems failure identified by the coroner, and set the tone for four days of confusion, oversight and communication failures from one doctor to another, which came to characterise her chaotic treatment.

At 12.30am on Monday, Savita's membranes ruptured. Miriam Dunleavy, an experienced midwife on duty that night, described in her evidence how she was called to Savita's room after midnight. Savita had vomited in the bathroom and her pyjamas were soaked. "A spontaneous rupture of the membrane had occurred," Ms Dunleavy said. She called to another nurse fetched towels and pads. They brought Savita back to the bedroom and changed her clothes and, according to Ms Dunleavy, Savita said she was starting to feel better.

Dr Katherine Astbury, a highly qualified consultant obstetrician and gynaecologist who was ultimately responsible for Savita's care, would later tell the inquest: "When a membrane ruptures, there is an open passage up to the uterus, so there is always a concern about infection."

As her consultant, Dr Astbury faced particular scrutiny at the inquest. She was the only member of hospital staff to have her own barrister, Eileen Barrington. If she was nervous, it didn't show. She came across as a steady and unemotional witness. She spoke clearly, stuck to the facts, and cited statistics and medical research when her decisions about Savita were questioned.

When she reviewed Savita on her ward rounds at 8.30am on Monday, October 22, she found no evidence of an infection. She sent Savita for an ultrasound scan to determine whether the foetus was alive or dead. "I discussed the rationale for this in terms of the risk of sepsis with ruptured membranes and therefore the need to avoid her sitting on the ward undelivered for a protracted period after foetal demise," she said.

Once a foetal heartbeat was detected, Dr Astbury's options were limited. As she repeated time and again under challenging cross-examination by Praveen Halappanavar's counsel, Eugene Gleeson, terminating the pregnancy at that stage was not an option.

Irish law permitted the termination of a foetus if there was a risk to life and at that stage, said Dr Astbury, Savita's life was not at risk. Her plan was to "await events". She prescribed an antibiotic called anthramycin to lessen the risk of infection, unaware of the blood tests suggesting Savita may have had a possible infection.

Unlike her junior colleagues, Dr Astbury also believed that there was "a very small prospect" that the foetus might survive. According to Praveen's evidence, however, the couple were given the impression that there was no hope of survival. So much so that Savita "could not take looking at her baby on the monitor", Praveen said, and she asked for a termination three times over two days, and claimed the consultant replied she couldn't, "because Ireland is a Catholic country".

Although he conceded that his recollection of some events was confused, he was adamant on this point. But Dr Astbury was equally insistent that it was not so.

She said Savita asked her to end her pregnancy just once – and that was on Tuesday morning when she saw her on her own at around 8.20am. Savita asked about "the possibility of us giving her medication to cause her to miscarry as the outlook for the pregnancy was poor and she did not want to have to await events". According to Dr Astbury, her exact words to her were: "In this country, it is not legal to terminate a pregnancy on grounds of poor prognosis for the foetus."

At 9.20am that Tuesday morning, Mrudula Vaseali, a close friend of Savita's, came to sit with her friend. Mrudula was among the first to know about Savita's pregnancy and how happy she was. She described how utterly devastated Savita was to lose the baby. They were alone. Praveen was driving Savita's parents, who had been visiting, to Dublin Airport and didn't get back until around lunchtime, she said. Savita was distraught, at one point saying: "What kind of mother am I, waiting for my baby to die?" At 11am or 12, Mrudula said a midwife came into the room to check the foetal heartbeat, but she couldn't continue with her work because Savita was crying so much.

Both she and Savita asked the midwife what they could do to stop the foetal heartbeat. According to Mrudula, the midwife replied: "We don't do that here, dear. It's a Catholic thing. Anything else we can do for you."

Can we identify the midwife, the coroner inquired, after Mrudula finished her evidence?

Ann Maria Burke, a midwife manager, later appeared before a packed court room, a kindly-looking woman in an orange cardigan and a black skirt, nervous and uncomfortable, but unflinchingly honest.

"Did you say to Savita, it can't be done, it's a Catholic country?" the coroner asked her gently. "Yes, to be honest. I'm upset about this. . . I'm very upset about this," she said. "I did mention a Catholic country. I didn't mention it in a hurtful context. . . She talked about India, she mentioned there was no problem taking a baby in India, and the Hindu faith was mentioned also. . . I did explain to her because I knew it wasn't possible to induce her because, I had been informed by the consultant, the foetal heartbeat was there. It was not in the context of offending her and sorry if it came across that way."

Ms Burke had other – arguably more pertinent – evidence to share with the inquest. She had assigned a student midwife under her supervision, Elaine Finucane, to watch Savita, who dropped in on her regularly during the day.

By 7pm on Tuesday 23, 43 hours had passed since Savita's membranes had ruptured. Under hospital policy, women in her condition were required to have their vital signs – pulse, temperature, blood pressure, respiratory function – monitored every four hours, because of the risk of infection. As the inquest revealed, this did not happen in Savita's case, with one large gap in time between readings of her vital signs.

However, at 7pm Elaine Finucane, took her pulse. Her heart rate was 114 beats per minute, from the usual rate of 89. An elevated pulse rate is one of four classic signs of sepsis. Ms Burke was concerned. She said she bleeped the junior hospital doctor on call, Dr Ikechuckwu Uzocwu, at 7.35pm. She said she asked him if Ms Halappanavar could have a bath and informed him of the elevated pulse. She was "absolutely certain" about this because she wanted his advice on it.

Dr Uzocwu, a senior house officer, had a different memory of the phone call altogether. He said he was contacted between 9pm and 11pm – by which time Ms Burke had gone off duty. He said he was told that Savita was "complaining of weakness" but that her vital signs were normal. He made no mention of a bath, and he thought he had spoken to a different nurse.

Had he known about her elevated pulse rate, he said he would have gone to Savita's bedside sooner. Instead, he looked in on her at 1am, when she was sleeping, so he did not disturb her.

Apart from another reading at 9pm, Savita's pulse was not checked again until the following morning. There were 15 patients in St Monica's ward and two nurses on duty, Miriam Dunleavy, and her colleague, who was excused from giving evidence to the inquest. According to Ms Dunleavy, Savita was "one of healthiest patients on the ward" that night.

At 4.30am, Ms Dunleavy answered a call from Savita's room. Praveen had claimed that his wife was shivering and her teeth chattering. Ms Dunleavy gave a different account: "Both Ms Halappanavar and her husband were awake. Ms Halappanavar said her husband was cold and that the room was cold. He was sleeping on a mat on the floor near the radiator," she said. She said she couldn't recall checking the radiator, as Praveen claimed. She pulled a blanket over Savita, she shivered once and noticed that her teeth were "clattering". She gave her paracetamol to bring down her temperature but didn't check her pulse: "that was my clinical decision", she said. She checked on her at 5.15am, when she said her temperature had lowered and Savita "snuggled" into her blankets.

Over the next 90 minutes, Savita's condition deteriorated rapidly. At 6.30am, she was feverish and her heart was pounding out of her chest. "I have never seen a woman with inevitable miscarriage get sick so quickly and I have been a midwife for seven years," said Ms Dunleavy.

Dr Uzocwu was the first to diagnose sepsis. Savita had a fever, high blood pressure and her heart was pounding at 160 beats per minute. A vaginal swab revealed a foul-smelling discharge, confirming his suspicions that her ruptured membranes were the probable source of the infection – a condition called chorioamnionitis.

Savita was put on a drip and stabilised. But "systems failures" continued to dog Savita at this crucial turning point in her condition.

The blood tests he took at 7am did not reach the laboratory until three hours later.

A lactate test – a key indicator of onsetting sepsis – taken at the same time and dispatched with her bloods, was returned untested because it was sent to the wrong place.

Even more critically, Dr Astbury was totally unaware of the junior doctor's note of "foul-smelling discharge" that pointed to chorioamnionitis, when she reviewed Savita at 8.25am.

In the corridor outside Savita's room, Dr Astbury's registrar, Dr Ann Helps, had a brief chat with Dr Uzocwu about the case, and he gave her his notes. Dr Helps said that he told her about the spike in temperature, and that she felt cold and unwell, but that he didn't tell her about the foul discharge. She couldn't remember reading it in his notes – although it was there – and she said she couldn't recall if she had told Dr Astbury about it. As for Dr Astbury, she had not read the notes, relying on her registrar to do so, and she insisted she hadn't been told.

Had she known about the foul-smelling discharge, Dr Astbury said, she would have acted straight away to terminate the foetus and remove the source of the infection.

Instead, she waited for the blood tests to come back. Under cross-examination, she said she suspected chorioamnionitis but wanted to rule out other potential sources of infection, such as the urinary tract. Savita's temperature had come down, she seemed to be responding to medication, and she believed that her sepsis was not severe. She felt it was "reasonable" to wait for the results of the blood tests that afternoon.

By lunchtime, however, Savita's condition deteriorated, her pulse was racing and her blood pressure plummeting. Dr Astbury sought the advice of a colleague before deciding to medically induce the foetus. She prescribed the medicine and at 2pm, she scanned for a foetal heartbeat. There was none. Dr Astbury believed she was going into septic shock.

At 3.15, she was moved into the care of a multidisciplinary team of consultants and nurses who battled in vain to save her life.

An expert witness, Dr Susan Knowles, a consultant microbiologist with the National Maternity Hospital, has said that the medical team should have moved earlier to get a second opinion on delivering the foetus; that the notes on her condition were poor; and she criticised the failure to check all her vital signs.

The inquest resumes on Wednesday and a verdict is expected before the end of the week. So far, the questions it has raised for the hospital are troubling.

A catalogue of systems failures

Sunday October 21

2pm: Savita, below, is admitted to University College Hospital Galway with a suspected miscarriage. Blood tests indicate possible infection but the results are not collected. Monday October 22

12.30am: Savita's membranes rupture.

8.30am: Scan shows foetus is still alive. Savita put on antibiotics to "lessen risk of infection".

Tuesday October 23

8.30am: Savita asks for foetus to be induced. Dr Katherine Astbury tells her law does not permit it while foetal heartbeat is there.

7pm: Savita's pulse rate elevated at 114. Midwife says she told on-call doctor about elevated pulse. He says he was only told she was weakening.

9pm: Savita's pulse rate is lower. It is not checked again for more than nine hours, in breach of hospital guidelines.

Wednesday October 24

1am: On-call doctor checks on Savita but she is asleep. He does not examine her.

4.15am: Midwife gives shivering Savita an extra blanket, paracetemol for a temperature but doesn't take her pulse.

6.30am: Savita's pulse is 160, she is running a fever and has a foul-smelling discharge. On-call doctor diagnoses sepsis, pinpointing probable source as her ruptured membranes.

7am: Blood samples taken but they don't reach the laboratory until after 10am. A lactate test – a key test for sepsis – sent back because it was mistakenly sent.

8.35am: Dr Astbury, left, reviews Savita, diagnoses sepsis, and awaits further tests. She tells Savita she may have to terminate. But, crucially, she is unaware of foul discharge. Her registrar, Dr Ann Helps, says she wasn't told, and she didn't read it in the notes.

1pm: Savita's condition deteriorates; her consultant seeks a second opinion before deciding to terminate. A scan reveals the foetus is dead.

3.15pm: Savita is admitted to theatre. While a central line is being inserted, she spontaneously delivers a baby girl they call Prasa.

4.15pm: Savita is transferred to high-dependency unit.

Thursday October 25

3am: Her condition deteriorates and she is transferred to intensive care.

Friday

October 26

10am: Savita is critically ill as test results show septicaemia caused by ecoli ESBL.

8pm: Dr Astbury calls to see her patient. .

Saturday October 27

Friends call to Savita and rally around Praveen, below.

Sunday October 28

12.45am: Savita suffers a cardiac arrest. Praveen is present as doctors try to resuscitate her. She does not respond.

1.09pm: Savita dies