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'Cascade of errors' led to Savita's death – expert


Praveen Halappanavar. Photo: Steve Humphreys

Praveen Halappanavar. Photo: Steve Humphreys

Praveen Halappanavar. Photo: Steve Humphreys

SAVITA Halappanavar was the victim of a "cascade" of clinical errors which meant the gravity of her condition was not recognised in time.

Ms Halappanavar died of septicaemia in her 17th week of pregnancy last October after being refused an abortion at Galway University Hospital even though she was mis- carrying.

Prof Sabaratnam Arulkumaran, who led the HSE clinical review of the tragedy, said if Savita had been his patient he would have terminated the pregnancy earlier.

"It may be possible that she would be alive if the treatment might have been different. I can't say definitely but the chances are it might have been better," he added.

Prof Arulkumaran was speaking at the release of the final report of the clinical review.

The Herald was the first paper to reveal details of the findings when we published extracts from the draft report last February.

The 108-page final report found there was:

* Inadequate assessment and monitoring of Ms Halappanavar to enable the clinical team to respond to her deteriorating condition

* A passive approach by medics and delays in aggressive treatment of her condition

* A failure to offer all "management options" to Savita who was experiencing inevitable miscarriage

* A non-adherence to the hospital's own clinical guidelines relating to the management of sepsis.

The report outlines a litany of errors and oversights.

Prof Arulkumaran described the "cascade effect or a domino effect" which hampered her care.

After the first blood test was ordered, nobody looked at the report and, when Savita suffered a spontaneous rupture of membranes causing fluid surrounding the baby to be released, "something else (was) missed and so on and so forth", he added.

"Every single step, they (medics) should have blocked the error from happening... It's a cascade of events that happened and one led to the other," he said.

The review records how Savita and her husband Praveen were "emotional and upset" when told that a miscarriage was inevitable on October 23.

The couple asked about the possibility of using medication to induce miscarriage, but were told by a consultant this was not permitted under Irish law.

In the early hours of October 24, a midwife noted how Savita's "teeth were chattering" so she took her temperature but didn't see any signs that the patient was septic.

Later that morning, the medical team discussed the possibility of a termination, stating that if her condition didn't improve she may have to be induced.

In the early hours of October 25, Savita was "noted to have ongoing clinical deterioration" and was transferred from the high dependency unit to the intensive care unit.



She remained "critically ill" throughout October 26, with the record of the gynaecology clinical review stating Savita was in septic shock.

The clinical review records that Savita suffered a cardiac arrest at 45 minutes past midnight on October 28 and was pronounced dead at 1.09am.

Speaking yesterday, Prof Arulkumaran, head of obstetrics and gynaecology at St George's University of London, noted how there is a lack of clarity in Ireland about when a termination can be performed.

Under the Constitution, a doctor can intervene when the life of the mother is at risk. But Prof Arulkumaran said the "option of offering a termination early if there is a suspicion of infection is not available here because of the legal situation".

He added: "In our report, we have said even to the last minute they are waiting for the foetal heart beat to disappear before the termination was considered."

Health Minister James Reilly said: "I have serious concerns about what this report reveals. It is a hard-hitting report which spares nobody and doesn't pull any punches. It lays bare a set of unacceptable factors that led to the tragic death of a young woman. We must study this report in great detail, learn the relevant lessons and consider how best to implement its recommendations."