HIQA investigation report, on the death of Savita Halappanavar, slams hospital failure to provide 'even the most basic elements of patient care'

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

appropriate 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

Savita 'died from rare infection'

SAVITA Halappanavar died from an extremely rare and aggressive infection which an expert from the National Maternity Hospital had only seen five times in his 40-year career. Independent report

Three experts told the inquest that the 31-year-old dentist had died as a result of septic shock with the presence of an antibiotic-resistant Ecoli infection – and this had caused her to suffer multi-organ failure.

The young woman had been strong and healthy prior to the aggressive infection spreading rapidly through her system.

The post-mortem found no evidence of any underlying condition that could have contributed to her death.

Dr Peter Kelehan, a former pathologist with the National Maternity Hospital in Dublin, who reviewed the post-mortem findings for the inquest, said there were "classic signs of septic abortion" present in the case.

Survived

He said such cases were extremely rare and he had only seen four or five cases in his 40-year career. In all of those cases the mothers had survived.

He added that of the 700 to 800 miscarriages he would have seen each year, it was highly unusual to come across the level of infection that was present in Savita's case. "It is exceedingly rare to find this level of inflammation," he said.

Dr Kelehan highlighted the need for swift action in cases of acute chorioamnionitis, an infection of the foetal membranes, and told the inquest that the infection grows rapidly in such cases as a result of the death of the placenta tissues during miscarriage.

According to Dr Kelehan, signs of septic abortion were evident in the placenta in Savita's case.

The expert witness agreed with Eugene Gleeson, counsel for Praveen Halappanavar, that such an infection would set alarm bells ringing when viewed under microscope, adding that it was "so important that you pick up the phone and make the call".

The former pathologist added that in his opinion the baby and placenta would have been dead before the rapid growth of this infection. "This is why it is so important to remove this tissues so quickly once the baby is dead," he said.

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Earlier the inquest heard from Prof Grace Callagy, of UHG, who carried out the post-mortem on Ms Halappanavar. She recorded the cause of death as septic shock with the presence of an 'esbl' strain of Ecoli infection. A further factor in her death was the miscarriage at 17 weeks associated with the onset of acute chorioamnionitis, an inflammation of the foetal membrane.

Prof Callagy told the inquest that multiple swabs had been taken which showed the infection had been an ascending infection that most likely originated in the patient's rectum and travelled up the genital tract to her uterus. She added that there was no other focus of infection found anywhere. This view was shared by Dr Kelehan and Dr Sebastian Lucas who is considered the foremost expert in sepsis in the UK.

Prof Callagy agreed with Coroner Dr Ciaran MacLoughlin that when Ms Halappanavar's membranes ruptured the patient was vulnerable to that infection. She added that she had rarely come across such a case.

Praveen Halappanavar did not attend yesterday's hearing, with his solicitor Gerard O'Donnell saying he had found earlier evidence very distressing.

Mr O'Donnell added that Mr Halappanavar would return to the inquest today to hear the jury's verdict.

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 Ciarán 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.