AN EXPERT witness has told how Savita Halappanavar was not on effective antibiotic care for a vital six hours on the day she became critically ill.
Consultant microbiologist Dr Susan Knowles also identified other shortcomings in the care of the 31-year-old dentist, when she gave evidence at Galway courthouse yesterday.
Dr Knowles told the inquest that Savita's medical team should have sought an earlier second opinion on when to deliver the foetus.
She added that in cases of chorioamnionitis, the infection of the membrane Ms Halappanavar was suffering from, early delivery of the foetus is essential.
Dr Knowles, a consultant microbiologist with the National Maternity Hospital, described the decision-making regarding induction of labour as "a critical part" of the management of this case.
She also raised concerns about the checking of vital signs, the failure to promptly diagnose the severity of the sepsis and the poor condition of the medical notes. Dr Knowles told how the antibiotic treatment Savita Halappanavar received from 7am to 1pm on Wednesday was not effective.
She gave evidence that a broader range of antibiotics should have been considered as Ms Halappanavar deteriorated. While she accepted that the antibiotics that were given from 1pm onwards were acceptable under certain guidelines, she stressed she would not have prescribed them.
Dr Knowles agreed with Eugene Gleeson, counsel for Praveen Halappanavar, that the protocol on antibiotic cover had not been adhered to up until 1pm on Wednesday, October 24.
Once Savita's condition was diagnosed at that stage it was clear the antibiotic cover Savita was on was not effective.
Mr Gleeson put it to Ms Knowles that the problem she had in this case was the antibiotics chosen to treat Ms Halappanavar, to which she replied: "Yes, I wouldn't have used these choices."
Commenting on Ms Halappanavar's diagnosis of chorioamnionitis on Wednesday, Dr Knowles said the condition required the quick delivery of the foetus. She agreed with counsel for Mr Halappanavar that there was no note on Ms Halappanavar's charts of any plan to deliver the baby.
Dr Knowles agreed that delivery of the foetus would be essential in such cases.
"Delivery will naturally happen but if you suspect chorioamnionitis you may have to expedite that," she said.
However, she said there was no need to deliver the foetus before Wednesday, as Ms Halappanavar's condition was not life-threatening at that stage.
She also raised concerns about the care of the young woman. She highlighted that not all vital signs were checked when Ms Halappanavar complained of feeling cold and was found to be shivering early on Wednesday morning.
At that stage Ms Halappanavar's temperature was taken but Dr Knowles stressed that all vital signs should have been recorded at this stage. She added that the medical team should have been aware earlier that Savita Halappanavar was deteriorating and the sepsis was more severe than thought.
Speaking about the delay in sending a blood sample to the lab, Dr Knowles said that while there were no clinical signs of infection at that time, "nonetheless it's important that if a sample is taken that it is followed up".
"The result that was found was unexpected in the clinical context but the team looking after Ms Halappanavar should have been aware of the result sooner," she said.
The inquest resumes on Wednesday when two witnesses are to be recalled in a bid to look at the "irreconcilable differences" between their evidence.
Dr Ikechkwu Uzockwu and midwife Ann Maria Burke gave conflicting accounts of a telephone conversation on the evening of Tuesday, October 23.
Earlier this week Dr Uzockwu also told the court that he was never informed about Ms Halappanavar's raised temperature on Tuesday, adding that he would have acted on this. This was despite the fact that a statement from midwife Ann Maria Burke read into the court said that she had informed Dr Uzockwu of the elevated temperature. Dr Uzockwu disputed this, insisting he had not been made aware.