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.
