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” where
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
