‘Savita might still be alive if 2007 case advice had been implemented’

Savita Halappanavar might be alive if Ireland’s maternity services had not failed to implement recommendations after a “disturbingly” similar death in 2007, a report has claimed.

The claim is made in the Health Information and Quality Authority’s (Hiqa) 257-page investigation into the death of the 17-weeks pregnant Indian dentist almost exactly a year ago.

The document, available at www.irishexaminer.com, mirrored the HSE’s report and the inquest hearing by again underlining serious errors in the 31-year-old’s care at University Hospital Galway last October.

However, for the first time in the scandal, the Hiqa investigation raised major concerns over wider maternity services in Ireland.

This includes the HSE’s failure to learn from past mistakes, including the 2007 death of Tania McCabe and her infant son Zach from septic shock after her membranes ruptured — a situation almost identical to what led to Ms Halappanavar’s death.

According to the report, after Ms McCabe’s death at Our Lady of Lourdes Hospital in Drogheda, a HSE- commissioned report asked Ireland’s 19 maternity services to implement recommendations to ensure a similar fatality never occurred.

Of these 19 facilities, just five — the Rotunda, Our Lady of Lourdes in Drogheda, the Coombe, the Mid-Western Regional Maternity Hospital in Limerick, and the Midland Regional in Mullingar — acted on the recommendation.

The 14 hospitals that failed to introduce changes include eight which made some changes and six which have no proof to show they responded to the advice at all.

However, it is unclear which of these categories relates to University Hospital Galway, where Ms Halappanavar died last year.

The Hiqa report was damning in its verdict of the lack of action, linking health service management’s inability to learn from past mistakes with Ms Halappanavar’s. “[Failure to implement the 2007 recommendations] raises a fundamental and worrying deficit in our health system,” said the report.

“Namely, the inability to implement change in a committed way and applying system-wide learning from adverse events... in order to prevent the recurrence of patient safety events that may cause harm, or worse, to future patients.

“[This is] demonstrated in the finding relating to the HSE enquiry into the death of Tania McCabe and her son Zach in 2007, the circumstances of which have a disturbing resemblance to the case of Savita Halappanavar.

“It is noted many of the recommendations had practical relevance in the case.”

Among the key recommendations from the 2007 Tania McCabe investigation were the need to ensure “early recognition” of sepsis in pregnant women; a national strategy for treating critically ill pregnant women; and an “urgent” upgrade of midwifery and medical staff levels to ensure the correct skill-mix is in place.