The HSE vowed this week to take “all action necessary” to ensure the safety and welfare of pregnant women and other patients attending UHG and its additional public hospitals in the region.
The undertaking came from Tony Canavan, the chief operating officer of the West/North West Hospitals Group, who said the organisation is “determined” to learn from the tragic death of Savita Halappanaver.
The 31-year-old Indian dentist, who was 17 weeks pregnant, died at UHG on October 28 last year from blood poisoning. She presented at the hospital a week earlier and was found to be miscarrying.
Mr Canavan was responding to a query from the chairman of the HSE West’s regional health forum Cllr Padraig Conneely who said the three reports into the death of Mrs Halappanaver - the inquest, HSE clinical review and HIQA report - made “damning reading” and were “embarrassing” for anyone involved in public health care.
Addressing a meeting of HSE West’s regional health forum Mr Canavan stated that Mrs Halappanaver death’s was the first maternal death in 16 years at UHG.
He outlined that the West/North West Hospitals Group met following the publication of the HIQA report to consider the findings and recommendations from the coroner’s inquest and both the HSE and HIQA investigations and to identify what further action needs to be taken.
He said after the meeting the hospital group announced that it will apply its established disciplinary process which is currently under way. “In the interest of restoring public confidence in the maternity services in UHG the group’s executive management team decided to include expertise from outside the hospital to assist in this process and to engage independent oversight of the processes employed by the review panel. We will take all appropriate action in light of these proceedings.”
Mr Canavan outlined that the HSE and HIQA reports have already been referred to the two regulatory bodies, the Irish Medical Council and the Nursing and Midwifery Board of Ireland. He added that the HSE was “co-operating fully” with this process which has already advanced to preliminary hearings in some instances.
He went on to remind forum members that a substantial element of the findings of the three investigations pertain to clinical judgement. He stressed that all the findings will be taken into account in its disciplinary proceedings and under standing orders the forum may not consider or make representations in respect of these matters.
He urged the forum to be mindful not just of the Irish Medical Council and the Nursing and Midwifery Board enquiries but also of the group’s own disciplinary procedures and also that Mr Halappanaver has initiated civil proceedings against UHG and a named consultant at the hospital.
Telling the meeting of the “devastating” effect of Mrs Halappanaver’s death on “many people” working at UHG he stressed that “no member of staff came to work during her care or any other day to do harm”.
Mr Canavan said that the HSE had made “considerable progress” in implementing the recommendations from both the HSE investigation and the coroner’s inquest. 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 improved communication procedures for doctors’ handovers. Other recommendations were the completion of specialist bereavement counselling training for key staff in the maternity department and the introduction of a new multi-disciplinary team based training programme in the management of obstetric emergencies.
