Galway University hospital failed to give Savita Halappanavar “even the most basic elements of patient care” according to a new and damning investigation conducted by the Health Information and Quality Authority (HIQA). The investigation identified thirteen “missed opportunities” whereappropriate intervention “may potentially have resulted in a different outcome for her”.
Mrs Halappanavar, who was 17 weeks pregnant, died of sepsis at University Hospital Galway on October 28 last year following a miscarriage.
The HIQA report says that following the rupture of her membranes Mrs Halappanavar should have received four-hourly observations, including checks on her temperature, heart rate, breathing and blood pressure. This did not happen, however, and hospital staff failed to act in a timely way to respond to her deterioration. By the time she was admitted to the critical care unit it was too late.
Among the key findings of the report are:
- The hospital did not follow its own guidelines on early warning alerts for a patient who could be deteriorating.
- It also ignored its guidelines on sepsis and pre-term pre-labour rupture of the membranes.
- Vital information about her condition was not shared by doctors looking after her.
- She was placed in a ward that was unsuitable for someone at risk of clinical deterioration which had not enough staff qualified to treat patients there.
The 257-page report from HIQA is the third report into Mrs Halappanavar’s death, and follows a coroner’s inquest and an inquiry by the HSE. It says the clinical governance arrangements within the hospital failed to recognise that vital hospital policies were not in use and points out that the Galway hospital developed a local Modified Obstetric Early Warning Score chart in 2009 but this was not in use on the ward three years later, in October 2012. It says there was no formal clinical escalation protocol and no emergency response team in place at the hospital and while sepsis guidelines were in place, clinical governance arrangements were “not robust enough” to ensure they were adhered to.
Commenting on the implications of the report consultant obstetrician DR Peter Boylan has described the HIQA report into the standards of maternity care as “an appalling indictment of State failure”.
It is abundantly clear from this new HIQA report and from the earlier reports that the real issue in this tragic case was never really about abortion but the basic deficiencies in patient care and the catalogue of failures in monitoring and recognising the grave risk to Mrs Halappanavar’s life caused by her sepsis infection.
Nevertheless this did not stop a ruthless and virulently pro-abortion media from using this tragic case to further its own agenda