Savita: Review team highlights litany of staff failings

Nursing staff failed to adequately assess and monitor Savita Halappanavar, who was suffering miscarriage as a fatal infection took over her body, a review has found.

The clinical inquiry into the death of the 31-year-old dentist found the most likely cause of her inevitable miscarriage was infection, with the risk of that infection and sepsis increasing after her waters broke.

Mrs Halappanavar died on Oct 28 at Galway University Hospital, a week after being admitted.

The review team highlighted a litany of failings that made a significant contribution to the Indian woman’s death:

- The interpretation of strict abortions laws that only allows termination when there is a real and substantial risk to a woman’s life;

- Staff did not adequately assess and monitor Savita as an infection took over her body;

- She was not offered all management options, including termination;

- Clinical guidelines relating to the prompt and effective management of sepsis at Galway University Hospital were also not followed, which includes removing the source of an infection.

Mrs Halappanavar’s waters broke in the early hours of Monday morning and her condition deteriorated in the early hours of Wednesday morning.

Her widower Praveen, who is out of the country, has maintained that she repeatedly requested a termination but was refused because a foetal heartbeat was present.

The report chairman, Prof Sabaratnam Arulkumaran, said the consultant’s plan to “await events” is appropriate when there is no risk to the mother or foetus, but stressed that monitoring and evaluation, as well as clinical investigations, would likely have led to reconsidering the need to expedite delivery.

The report found there was an over-emphasis on the need not to intervene until the foetal heartbeat stopped and not enough emphasis on the need to monitor and manage risk of infection.

“The interpretation of the law related to lawful termination in Ireland, and particularly the lack of clear clinical guidelines and training, is considered to have been a material contributory factor in this regard,” the report said.

The Government moved to introduce legislation for limited abortion, as required by a 1992 ruling in the Supreme Court, on the back of a public outcry over Mrs Halappanavar’s death.

Prof Arulkumaran recommended that clinicians, health and social care regulators, and politicians consider the law and guidelines on the management of inevitable miscarriage early in pregnancies and where there is a risk to the mother from infection.

The long-awaited report has been published two months after an inquest jury ruled unanimously that Mrs Halappanavar’s death was by medical misadventure.

The misadventure verdict found there were systemic failures or deficiencies in Mrs Halappanavar’s care before she died, but coroner Ciaran MacLoughlin said these failures did not contribute to her death.