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Maeve Sheehan: Grieving husband still searches for answer to burning question – why?

TOMORROW morning Praveen Halappanavar will take his seat in Galway court house and hear for the first time the facts of his wife's death laid out in a public forum.

She was a 31-year-old dentist who died of blood poisoning in University College Hospital Galway, after suffering a miscarriage on October 28. According to her husband, she was told that she couldn't have an abortion because Ireland was a Catholic country.

Her death had ramifications far beyond the grief of her husband, her family and friends, reigniting an acrimonious debate on abortion that has polarised Irish society for decades. It prompted thousands to take to the streets in silent candlelit protests; international headlines zoned in on the backward country whose Catholic ethos loomed large in the death of a pregnant young woman.

But as the inquest unfolds over the week, the story behind her death may well be a more prosaic one, a series of misjudgements, inadequacies and an apparent confusion over the law that culminated in a tragedy that shocked the country.

Up to 16 witnesses are expected to be called from the hospital, including the consultant obstetrician, doctors, nurses and specialists from other medical disciplines who were called in when she became critically ill.

The inquest is their first opportunity to give their account of what happened, after several months of fierce, and no doubt traumatising, public and private scrutiny.

Some of what they have to say is already included in a draft report on her death by an expert review group, commissioned by the Health Service Executive .

The report, based on interviews with 26 staff members, is a non-judgemental hourly chronicle of the medical treatment she received from the time she was admitted to hospital suffering a miscarriage to her death seven days later.

A copy of it was given to Praveen on Good Friday and a copy was also given to the coroner, although it won't be published until after his solicitor Gerard O'Donnell has issued a response. Mr O'Donnell said last week that while the report told them what happened to Savita, he and his client were still at a loss as to the reasons why it happened. Six months ago, Savita, a dentist, and Praveen, a chemical engineer, were looking forward to their first baby. Her parents had been visiting from India. They were on their journey back home when Savita became unwell with back pain. On Sunday, October 21, she went to hospital that morning at 9.35am, and went home again.

Still feeling unwell, she returned that afternoon, and was admitted at 3.30pm.

The draft report records the facts of her condition: how medical staff diagnosed that she was miscarrying, that blood tests were taken, and that the medical staff expected that the foetus would be delivered over the following hours or overnight. It records how the blood tests came back that same day to show that her white cell count was elevated, indicating that she was fighting an infection. It seems that the medical team expected a natural delivery of the foetus in a matter of hours, or overnight. They adopted a "wait and see" approach.

In the event, the foetus survived for three days. In that time, Savita was treated with a low dose of antibiotics, while medical staff monitored the foetal heartbeat, waiting for its death to take its natural course.

"She did mention (to Praveen) when she was given her first dose of antibiotics that it was of such magnitude that you would have given it to a baby. So it was a very low level of antibiotics – even though she had an infection," Mr O'Donnell said.

"She was a dentist herself. She mentioned it to Praveen and Praveen said that she was sort of bemused that this was what they were giving her that it was of such a low dose that it might be given to an infant."

On Tuesday evening her condition worsened. Praveen has recounted how she was shivering and teeth were chattering. The draft report notes that "the radiator in her room was not working". This was cited as among the reasons why it was thought that she was cold and why staff gave her "an extra blanket" – as recorded in her medical notes.

Elsewhere, the report notes that there was "inadequate assessment and monitoring" of her condition and identifies several communication breakdowns. Tests were not followed up. Actions were not followed through.

According to Mr O'Donnell, it suggested "information not being transferred across from one to the other, people saying it's not my job to follow up something. There's an element of 'it's not my responsibility'."

Praveen has said that both he and Savita had repeatedly asked for the pregnancy to be terminated, on the Monday and again on Tuesday. The draft report records just one of the couple's numerous requests for a termination. At one point, a staff member promised to make an inquiry on his behalf and to report back: "The doctor said unfortunately the foetus is still alive and it's a Catholic country and we won't be able to terminate. That's what the doctor said. Savita was insisting that she's not a Catholic and she's not Irish either so why impose the law on her," Praveen has said.

That loaded phrase – "it's a Catholic country" – made international headlines in the aftermath of Savita's death. According to sources close to the hospital, however, if the matter is raised at the inquest, the use of the phrase will be "clarified", in terms of who said it and the context in which it was uttered.

In any case, according to the draft report the issue of terminating Savita's pregnancy was not discussed until Wednesday, her fourth day in hospital and the foetal heart still beating.

By that point, Savita's condition had worsened over night. She was seen by the consultant on ward rounds on Wednesday morning at 8.30am. Blood tests were taken.

According to the draft report, there was a discussion on a termination but there was a "difficulty in the interpretation of the law".

If the medical team found the Irish laws on abortion difficult, the Medical Council guidelines in this area – published on its website – could have helped provide clarity. The guidelines state that in exceptional circumstances, when there is little or no hope of the baby surviving, "it may be necessary to intervene to terminate the pregnancy to protect the life of the mother, while making every effort to preserve the life of the baby".

In Savita's case, there was no chance of the baby's survival – she had been told this from the outset. So the next question is did the doctors believe that Savita's life was in danger at this critical juncture in her care?

The draft report on her death states: "Once sepsis is present, foetal demise is certain and the risk to the mother of developing severe sepsis with its sequela of serious morbidity and high mortality increases."

In Savita's case, the report says that "different management options needed to be considered including termination of pregnancy as the removal of the source of infection reduces the potential risk of sepsis, thereby potentially avoiding rapid deterioration in the patient's clinical condition."

Given this finding, it's likely the medical team will be closely examined on their reasons for not terminating the pregnancy at this point.

"Why, when there was never a question of the foetus surviving, why they didn't use everything possible to ensure that nothing would happen to Savita, knowing that she had an infection, and knowing that there were fully ruptured membranes that would have opened up the body for infection?" said Mr O'Donnell.

"So, therefore, the big question is when they knew all that, why did they not just intervene? Someone is going to have to give Praveen Halappanavar that answer?"

By Wednesday afternoon, on her fourth day in hospital, a second blood test showed that Savita had sepsis and she was placed under the care of a multi-disciplinary team. According to Gerard O'Donnell, she was rushed to theatre. "The purpose of being brought to theatre was to have a central line put in so that they could administer whatever medication they needed to quickly and in the process of that being done, there was a spontaneous delivery," he said.

"The purpose of installing this line was solely to make sure there would be drugs administered quickly. I don't know when it was intended that there would be a delivery. It was really only at that point in time that the emphasis switched to her care." She was moved from the high-dependency unit to intensive care. But the intervention was too late. She would later go into septic shock and in days she would be dead.

All the while, Praveen was unaware of the gravity of her condition, believing that she was "stable". "It was only on the Thursday evening that he finds out it is serious, but that she's stable and he doesn't realise the gravity of her situation until Saturday morning, when the family should be told. Nobody bothered to take him aside and tell him what had happened," said Mr O'Donnell.

According to the solicitor, Praveen believes that if the request for a termination had been granted, she would be alive today.

The report does not state this. What it does conclude is that "the investigating team considers there was an apparent over-emphasis on the need not to intervene until the foetal heart stopped, together with an under-emphasis on the need to focus an appropriate attention on monitoring for and managing the risk of infection and sepsis in the mother".

It is up to the coroner, Dr Ciaran McLoughlin, to decide whether and to what extent this fatally lopsided care given to Savita and her foetus should be teased out during the inquest into her death.

To Praveen Halappanavar, it goes to the heart of his quest to establish the why – not the how – of what happened.

"He wants to know why this happened to his wife and why there was an under-emphasis on her treatment and an overemphasis on a foetus that was not viable," said Mr O'Donnell.

"Nobody's infallible. So you can understand a single action which might be poor judgement by a particular individual on the day.

"But this is a multiple of actions by a multiple of people. . . over a period of time."

Irish Independent