Maeve Sheehan: Fears linger after three inquiries into Savita horror
Damning Hiqa report brings some answers – but not yet closure – for her devastated family, writes Maeve Sheehan
AFTER three inquiries into the death of Savita Halappanavar, "accountability" is finally seeping into the arena, the family's solicitor Gerard O'Donnell told the Sunday Independent this weekend.
The third and final inquiry into the death of the 31- year-old dentist from blood poisoning at Galway University College Hospital, the report by the Health Information & Quality Authority (Hiqa) goes further than the others.
It says that responsibility rests with her consultant, Dr Katherine Astbury, although she is not named. "Ultimate responsibility rested with the consultant obstetrician who was leading Savita Halappanavar's care."
Her medical team had failed to ensure she got the right care at the right time.
There isn't a word about the lack of clarity on Irish abortion law which her consultant, Katherine Astbury, has suggested hampered her treatment of Savita. Instead, there is further confirmation that bad medicine, rather than bad law, contributed to her death.
Within hours of publication of the health watchdog's report, wagons circled. The board of the Galway Hospital Group, in whose care Savita died, will meet on Tuesday. It is almost that disciplinary action against medical personnel in charge of Savita's care will be considered.
The chairman of the regional health forum, Padraig Conneely, has already called for scalps. He called last week for the consultant responsible for Savita's care and the clinical director of the hospital to be "stood down". He too has convened a meeting of the forum at which disciplinary action against the medical team in charge of Savita's care will be top of the agenda.
Meanwhile, the Medical Council and An Bord Altranais, the relevant professional bodies, are studying Hiqa's report. And if no one in authority makes a formal request to the Medical Council to examine Dr Astbury's professional conduct, Praveen Halappanavar almost certainly will.
What's different about Hiqa's report is that it goes closest to apportioning blame. At the inquest, Dr Astbury gave her testimony without admonishment or judgement, at the conclusion of which Savita was found to have died by medical misadventure. A clinical review commissioned by the HSE highlighted failings in the care she received but staff were not identified in that report, in the interests of getting at the truth.
Hiqa's findings are in marked contrast to testimony at the inquest into Savita's death. Then lawyers for the hospital argued that to censure staff would be unbalanced and unjustified. The inquest had heard evidence from an expert witness – the former master of Holles Street, Peter Boylan – that the only thing that might have saved Savita was a termination within a day or two of being admitted to hospital.
By the time it was lawful to perform a termination, Savita was beyond saving. Everyone had done their best. No one could be reproached, and an inquest was not the forum for finger-pointing.
But Hiqa identified 13 "missed opportunities" for intervention that could have altered the outcome for Savita.
She was admitted to the Galway hospital on October 21 last year, 17 weeks pregnant and having a miscarriage. The first "missed opportunity" arose that night, when her bloods came back from the lab showing she had an elevated white cell count, an indicator of infection.
Later that night, Savita's membranes ruptured, flagging up the next "missed opportunity". Her "vital signs" of temperature, heart rate, respiration and blood pressure, should have been monitored and recorded every four hours. They weren't, because the the relevant system wasn't in place on the ward.
Dr Astbury did not start work until Monday morning, so perhaps there was little she could have done about Savita's treatment that Sunday night.
But according to the health watchdog's report, intervention should have kicked in when she saw Savita at 8.20am on her ward rounds that Monday morning.
According to the health watchdog, neither the consultant, or her team, nor the nurses or midwives caring for Savita, reviewed the blood test results. At the inquest, Dr Astbury questioned whether this would have made a significant difference to Savita's care.
But the health watchdog was clear: "The elevated white cell count should have alerted staff to investigate the cause. . . further."
Not only that, but the care plan Dr Astbury drew up for Savita after examining her on her ward rounds that Monday morning was not comprehensive enough.
At the inquest, Dr Astbury defended the approach she took with Savita, which was to "await events", in other words for the miscarriage to occur naturally. The health watchdog indicated clearly that this was not enough, even at that early stage.
According to the report, the "clinical facts" were that infection was the most probable cause of her inevitable miscarriage and the risk of infection was increasing after her membranes ruptured.
Savita's care plan should have "contained elements to address and investigate" these clinical facts.
Over the next 15 hours, Savita's blood pressure and heart rate indicated clinical deterioration – and the fourth "missed opportunity" to intervene with appropriate treatment. The signs were not recognised by staff.
When Dr Astbury saw Savita again on her ward rounds on Tuesday morning at 8.30am, 24 hours had passed since her membranes had ruptured. The risk of infection had increased, yet Dr Astbury had started her on an antibiotics after 21 hours. Her vital signs indicated clinical deterioration as a result of infection. But the clinical staff in charge "did not recognise, document or manage" the risks to Savita.
At this point in the chronology, Ireland's abortion law entered the picture. Dr Astbury justified her reluctance to remove the foetus because the law would not allow her while a foetal heartbeat was present. She didn't think at that stage that Savita's life was at risk.
But the issue does not feature on Hiqa's radar. That Tuesday evening and into Wednesday morning staff presented a string of opportunities missed as Savita's body gave out signal after signal of her deteriorating state.
On Tuesday night, her heart raced over a five-hour period – at 7pm it was 114 beats per minute – but nursing staff did not recognise the significance.
This, in Hiqa's view, was another missed opportunity. The nursing staff caring for her "did not appear to recognise the urgent need to escalate her care and request that she be reviewed by another doctor".
Overnight, Savita had vomited, was shivering and had a raised temperature. But the midwifery/nursing staff didn't recognise that shivering, vomiting and raised temperature were a sign of sepsis.
By 8.25am, Savita's condition had deteriorated so much that a junior doctor had given her antibiotics and diagnosed suspected sepsis. When Dr Astbury reviewed Savita on her ward rounds, she noted the elevated pulse rate and temperature and prescribed additional antibiotics.
She noted that blood cultures and tests were pending, and took a vaginal swab and a urine test to test for infection.
But according to Hiqa, she "did not appear to recognise the significance of the diagnosis of chorioamnionitis with probably sepsis".
Hiqa noted that if any of these 13 missed opportunities had been acted on, they may have potentially changed the outcome of her care.
In its report, Hiqa suggested that the Galway hospital group should refer the nurses and doctors who treated Savita to their professional bodies.
"Patients and members of the public are entitled to expect the highest level of healthcare. When the delivery of care falls below that level, they are entitled to ask why and be assured that measures have been taken to protect them and future patients from harm," it said.
Last week, Dr James Reilly and other government figures latched on to the poor medical care Savita had received in hospital. When Hiqa's criticisms of staff shortages in maternity services were thrown at him, Dr Reilly said that no staffing issue can "explain away" the lack of basic clinical care given to Savita Halappanavar.
But while Hiqa singles out Savita's consultant as being ultimately responsible for her care, the report's most alarming findings related to the people charged with running the health service, who had clearly failed.
It highlighted the disturbing similarities in the death of Tania McCabe and her son, Zach. Six years on, the recommendations made by an inquiry into the garda sergeant's death have not been implemented.
In the Dail last week, Mary Lou McDonald, the Sinn Fein TD, was blunt: "Of course the implications of the report go far beyond (St Monica's) ward. We now see a mirror held up to our maternity services, showing us clearly that the vital safeguards, and the most basic provisions in terms of good governance and good practice in our maternity services, simply are not there. The authors of the report found it impossible to provide assurances that women are receiving safe or reliable care during or after pregnancy," she said.
While a question of negligence arises, the implication of this report "moves from St Monica's ward, through the HSE to the desk of the Minister for Health, and then it lands fairly and squarely on the desk of the Cabinet", she added.