A report by the Health Information and Quality Authority (HIQA ) into the death of Savita Halappanavar is due to be published by the end of the summer, the first public meeting of the board of the Galway and Roscommon University Hospitals Group heard this week.
The meeting also heard how a number of serious and worrisome threats had made against staff working at Galway University Hospital where Ms Halappanavar tragically passed away last October. Many of the threats were so severe that it warranted contacting the gardai.
The meeting which is part of the process of amalgamating hospital services took place on Tuesday where group clinical director Dr Patrick Nash explained that no exact date had been set for the publication of the results of the HIQA inquiry but that it is believed it could be the end of the summer, or perhaps early autumn.
It was also revealed at the meeting that following the death of Savita a number of staff have been on stress-related leave and that this has been compounded by correspondence received which were of a vile and distressing nature with some staff being accused of murder.
UHG and HSE is fully committed to implementing report recommendations
The HIQA report is the third inquiry into the death of Savita and follows a coroner’s inquest and a HSE Clinical Review report which was published last week. In a statement following the release of this report, Dr Nash said: “Firstly, on behalf of UHG, I would like to sincerely apologise to Mr Praveen Halappanavar and family for the events related to his wife’s care that contributed to her tragic death.
“UHG is committed to operating to the highest standards. We can reassure all concerned that we have already implemented changes to avoid the repeat of such an event. Mr Halappanavar has stated that he does not want any other woman go through what happened to his wife. The recommendations from this review will result in changes and improvements that will minimise the risk of this ever happening again in Ireland,” said Dr Nash, who added that the death of Ms Savita Halappanavar was the first direct maternal death at UHG in 16 years.
Dr Nash also acknowledged that the report clearly shows there were failures in the standard of care provided at UHG and confirmed that in response to the interim safety recommendations significant improvements have already been made. These include the implementation of early warning scoring systems, the education of staff in the recognition, monitoring, and management of sepsis and septic shock, and the introduction of a new multi-disciplinary team-based training programme in the management of obstetric emergencies including sepsis. Improvements have also been made in the communications processes as well as the implementation of ISBAR for doctors’ handovers.
“UHG and the HSE will work to fully implement all the recommendations arising from the report,” said Dr Nash.
The coroner’s inquest, which took place in April, found there had been a number of deficiencies in the care of Savita and that she could have been still alive today had a request for a termination been carried out one or two days after being admitted to hospital. The 31-year-old Indian dentist, who was 17 weeks pregnant when she presented to UHG suffering a miscarriage on Sunday, October 21, succumbed to septic shock and passed away on Sunday, October 28, from multiple organ failure and cardiac arrest.
A HSE review report identified three overall causal factors which include: the “inadequate assessment and monitoring of Ms Halappanavar that would have enabled the clinical team in UHG to recognise and respond to the signs that her condition was deteriorating”; the “failure to offer all management options to Ms Halappanavar who was experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to her was increasing with time, from the time that her membranes had ruptured”; and “the UHG’s non-adherence to clinical guidelines relating to the prompt and effective managment of sepsis, severe sepsis, and septic shock from when it was first diagnosed”. The investigation team, which was chaired by independent expert, Professor Sir Sabaratnam Arulkumaran, professor and head of obstetrics and gynaecology and deputy head of clinical sciences at St George’s University of London, made a number of recommendations to address the key contributory factors.
Galway Pro-Choice criticised the “rushed manner” in which the report was release and that it “shows a lack of courtesy” to Mr Halappanavar who was out of the country at the time. Group member, Rachel Donnelly said: “This report highlights how the eighth amendment to our constitution interferes with medical care in our State with grave consequences. We must repeal the amendment to protect women’s lives and ensure that doctors can provide all management options and not be bound by law to put a feotal heartbeat before a woman’s life.”
In their statement, the Pro Life Campaign welcomed the report as it highlights the multiple failures to properly assess and monitor Savita’s condition and the failure to recognise the very real risk to her life posed by serious infection. “If this risk had been recognised the outcome might have been very different,” said spokesperson Dr Berry Kiely, who added that the report “confirms what the Pro Life Campaign has always claimed, that the way some politicians and media fastened on Savita’s tragic death as somehow bolstering their call for abortion legislation was misplaced and even opportunistic”.
