James Reilly, the health minister, described the HSE inquiry as “a hard-hitting report which spares nobody and doesn’t pull any punches”.
He said the probe had raised “serious concerns” and he was now referring the report to the Medical Council and the Nursing and Midwifery Board.
“It lays bare a set of unacceptable factors that led to the tragic death of a young woman.
“We must study this report in great detail, learn the relevant lessons and consider how best to implement its recommendations,” he said.
He said the clinical inquiry — headed up by Sabaratnam Arulkumaran — identified key causal factors and contributory factors that led to the tragic death of the 31-year-old in October of last year at University Hospital Galway.
In particular, it exposed inadequate assessment and monitoring of Indian dentist Mrs Halappanavar, a failure to offer her all options as she faced an inevitable miscarriage, as well as non-adherence to clinical guidelines, Dr Reilly said.
Dr Reilly said Mrs Halappanavar’s widower Praveen and her family have had to endure a terrible loss that should never have occurred.
“We must all work together to ensure that the lessons are learned and implemented to prevent such a tragedy occurring again.”
Sinn Féin health spokesperson, Caoimhghín Ó Caoláin, said that medical staff needed to be held to account. “The report does not identify individuals involved in the care of Savita but there will be a justifiable public expectation that if serious lapses by individuals, as well as systems, occurred then individuals should be held to account.
“Like the outcome of the inquest, this report is a damning indictment and has far-reaching implications.
Mr Ó Caoláin added: “It is extremely serious and distressing that the report has found that Savita’s death resulted from inadequate assessment and monitoring of her condition, failure to offer all management options to her, and University College Hospital Galway’s non-adherence to clinical guidelines relating to the prompt and effective management of sepsis, severe sepsis and septic shock from when it was first diagnosed.”
The Sinn Féin spokes-person insisted the report’s recommendations must now be complied with.
“One of the key recommendations highlights the need for clear legislation and guidelines on termination to save the life of a woman.
“This is directly relevant in the context of the publication today of the Protection of Human Life in Pregnancy Bill 2013 and the guidelines which are due to follow,” he said.
The HSE clinical review is one of three investigations set up in the aftermath of Savita Halappanavar’s death. The remaining two include the inquest, which finished in April, and a still-to-be-published Hiqa inquiry into the incident.
An 11-member jury took two hours and 40 minutes to unanimously support coroner Dr Ciaran McLoughlin’s verdict that Mrs Halappanavar died as a result of “medical misadventure”.
The conclusion raised particular concerns about blood samples failing to be followed up; a lack of clarity on when doctors could intervene in a pregnancy to save the life of the mother; poor sepsis management training and guidelines; and a lack of effective communication between hospital staff.
Dr McLoughlin also raised concerns over medical and nursing notes, insisting they should be kept separate from each other and that alterations should not take place.
The hearing also finally uncovered the truth behind the “this is a Catholic country” remark. Ann Marie Burke, midwife manager on St Monica’s Ward at Galway University Hospital, told the hearing: “She [Mrs Halappanavar] had mentioned the Hindu faith and that in India a termination would be possible. It had come out the wrong... I was trying to be as broad and explanatory as I could. It was nothing to do with medical care at all.”
While the inquest uncovered new details on what happened, it was not within the realm of the ’ court to hold anyone directly responsible.
After Mrs Halappanavar’s family raised concerns over the alleged lack of transparency in any HSE-run inquiry, pressure was placed on Hiqa to open its own investigation.
After a formal request from the Irish Patients’ Association, this independent inquiry was set up last November.
Hiqa’s team is continuing to work on the report, which is tasked with seeing Mrs Halappanavar’s death in the context of what potential hidden dangers may exist for other women facing similar circumstances in Ireland’s maternity services.
The Hiqa team is led by Belfast gynaecologist Dr Paul Fogarty.