Wednesday, April 17, 2013

Savita Inquest: System failures in Galway University Hospital caused delay in diagnosis of sepsis

The inquest into the death of Savita Halappanavar has now entered its second week and many of the previously unanswered questions are being addressed.
Consultant microbiologist Dr Susan Knowles from the National Maternity Hospital, told the inquest last week that delivery of the unborn baby was not warranted before the diagnosis of chorioamnionitis was suspected on Wednesday October 24 following her hospitalization the previous Sunday. Dr Knowles added that it was her understanding that there was no substantial risk to Savita's life on Tuesday - the day that Savita had requested a termination.

Several failures in the hospital system meant that signs of an infection had been missed and sepsis developed rapidly on Wednesday October 24th, leading to the tragic death of Ms Halappanavar four days later.

The crucial issue is that sepsis was missed because of several failures to follow up on and communicate test results. E.coli ESBL, however, also remains very resistant to antibiotics.

The inquest uncovered a series of errors and ‘systems failures’ in Galway’s University Hospital. A crucial blood test that should have triggered alarm bells was not followed up on, and the consultant obstetrician was unaware of “significant” information written by another doctor in the patient’s notes.

Coroner Dr CiarĂ¡n MacLoughlin believes he has identified a number of systems failures that occurred in Mrs Halappanavar’s treatment, including a failure to monitor her condition regularly and a failure to pass on the result of key medical tests and observations.

Consultant Obstetrician Dr Katherine Astbury said she would have begun to terminate the pregnancy sooner, regardless of a foetal heartbeat, if she had been aware of a junior doctor’s note that the patient was suffering from severe sepsis. She admitted at the inquest that on the day Mrs Halappanavar miscarried, October 24, she did not know a junior colleague had put on her chart at 6.30am that he suspected Mrs Halappanavar was suffering from sepsis caused by chorioamnionitis, an infection of the foetal membrane.