Entries on chart not meant to ‘mislead’

Retrospective entries made in the medical records of Savita Halappanavar were not made with the intention of misleading anyone and nothing had been deleted, senior counsel for Galway University Hospital has insisted.

The inquest into the death of Mrs Halappanavar on Oct 28 last heard that there were eight retrospective entries out of a total of 110 pages of medical notes.

Senior counsel for the hospital and the HSE, Declan Buckley, told coroner Dr Ciaran MacLoughlin that these comprised five “contemporaneous retrospective” notes. Because of an emergency, medical staff may have had to defer for an hour the writing up of a particular note, he explained.

The other three were “classic retrospective notes”. These had clearly been marked “retrospective notes” and dated to confirm they were made retrospectively.

Mr Buckley explained that, during Mrs Halappanavar’s time in hospital, she had been transferred from her ward to a theatre and onto the high dependency unit and then to the intensive care unit, before going to pathology.

Her chart always accompanied her and staff may not have had the opportunity of completing their notes before it left with the patient. When the chart returned, the clinical risk manager took the view that all of the information about the event should be provided on the chart.

The dates of the entries were spread out because some people were on leave and it was November before some entries were inserted. In addition, theatre nurses had completed a report — something they would not normally do. But in light of the event, they had written out what they remembered and inserted it in the chart.

“This should be viewed in the light of the serious tragedy that occurred. This was the first maternal death in the hospital in 16/17 years.

“There was never any intention to mislead anyone. None of the original entries were deleted,” Mr Buckley said.

The coroner had earlier expressed surprise at the number of retrospective entries in the notes. He told the inquest on Wednesday that he had never seen so many retrospective notes on a patient’s chart.

He queried an entry for Wednesday, Oct 24, by which stage Mrs Halappanavar had developed severe sepsis and Mr Buckley said he would seek to have the entry clarified.

Praveen Halappanavar’s solicitor, Gerard O’Donnell said it was now likely that he would wait until the inquest had concluded before meeting the chairman of the HSE inquiry into his wife’s death.