UHG and national maternity care slammed
University Hospital Galway (UHG) failed to provide the most basic elements of care to Savita Halappanavar, the latest damning inquiry into the circumstances of her death 12 months ago has found.
The report by the safety watchdog HIQA also raises serious questions about what it feels is the lack of a proper safety culture in maternity services nationally.
Health Minister James Reilly said the report made for 'very disturbing reading.'
The newly-published report of the probe has identified a number of missed opportunities to intervene in Savita's care which, if acted upon, may have resulted in a different outcome and saved her life.
The HIQA goes further than a preious HSE review in highlighting accountabilty for what went wrong. It stresses that ultimate responsibility for Savita's care lay with the consultant obstetrician leading her care and says employers should be held accountable for upholding safety standards in maternity services.
The report has also identified deficits in the provision of maternity services nationally, with a number of concerns expressed in the report about the implementation of safety standards in maternity units.
HIQA says it is impossible at this time to assess properly the performance and quality of maternity services nationally.
For example, the report shows that many maternity units have not fully implemented 2007 recommendations on dealing with seriously ill maternity patients issued following the death of Tania McCabe from septic shock at Our Lady of Lourdes Hospital in Drogheda.
HIQA has expressed concern that six years on from the Tania McCabe recommendations, the fact that only five of the 19 public maternity hospitals/units were able to provide it with a detailed status report on the implementation of the recommendations from that report is 'simply unacceptable'.
It says senior maternity hospital managers and the HSE should be held to account as regards implementing these recommendations.
While parts of the report echo the care failings uncovered in the previous HSE report and coroner's inquest into the case, the HIQA report also goes further in its findings and recommendations and is quite trenchant in it criticism of maternity services and those who operate them.
HIQA points to staffing and resource inadequacies on the ward where Savita was treated to effectively deal with emergency maternity cases and the diverse patient casemix on the ward.
It says consultants on-call for the UHG labour ward were not present on the labour ward but were engaged in other clinical activities, and there was no anaesthetist dedicated solely to the labour ward during core working hours or on-call.
The report makes extensive recommendations on the need for improvements in the safety standards in maternity services nationally.
On national maternity services, HIQA states that pregnant woman need assurances that they are receiving safe, high quality and reliable care during and after their pregnancy, and to ensure this, services must collect, monitor and manage quality and safety performance measures to evaluate the performance of their clinicians and outcomes for patients.
The safety body has called for a national maternity services strategy to be developed 'which will move us towards a demonstrably high quality, safe and best practice model of maternity care across the country'.
The HIQA report goes further than the HSE's own probe, in recommending that UHG and the HSE should examine the 'actions, omissions and practices' of the professionals involved in the Savita case and make appropriate referral or referrals to the relevant regulatory bodies.
Health Minister James Reilly back in June referred the findings of the HSE review to the Medical Council and Nursing and Midwifery Board for consideration.
The report stresses the need for 'ownership, accountabillty abnd responsibility' within the health service to implement changes following adverse incients.
The HIQA report proposes that the Department of Health should develop a 'code of conduct' for health employers that clearly sets out employers' responsibilities to achieve an optimal safety culture, governance and performance of health organisations. This code would outline managers' responsibilities to achieve these aims, including the need where necessary to refer professionals to the appropriate regulatory bodies.
HIQA's Director of Regulation Phelim Quinn said there had been a failure to recognise that Savita was developing an infection and then a failure to act on the signs of her clinical deterioration.
Savita was 17 weeks pregnant when she died as a result of sepsis on October 28, 2012 at University Hospital Galway following a miscarriage.
HIQA said while Savita died from sepsis, it could not find a nationally-agreed definition of maternal sepsis and also found inconsistencies in the recording and reporting of maternal sepsis nationally. It wants the HSE to develop a national guideline on managing sepsis.
HIQA said in the Savita case, UHG did not have effective clinical arrangements in place to ensure regular monitoring of the patient, to act on any danger signs and to ensure a seamless clinical handover of information relating to each patient within and between clinicians and clinical teams.
"Our investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which were not consistent with best practice," Mr Quinn said.
He said there had been a series of missed opportunities to intervene in Ms Halappanavar's care pathway which, if acted upon could have changed the outcome for the patient.
The report states that there was a failure on the part of Savita's clinical team to recognise that she was at risk of clinical deterioration and developing sepsis. There were also deficiencies in the documentation of the case, HIQA found.
It says the most senior clinical decision maker involved in the care of Savita at any given time should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly. The report says ultimate clinical responsibility rested with the consultant obstetrician leading the patient's care.
HIQA findings in relation to Savita's care at UHG also included that hospital guidelines on the local maternity early warning score or management of sepsis were not followed; that there were inadequate staff handover arrangements; that vital information on her condition was not recorded, shared or responded to by staff; and that there was inadequate staff training and management of sepsis and deteriorating patients.
The report also found inappropriate access to emergency ultrasound on the ward where Savita was treated and inadequacies in the workforce to deal with patient casemix on the ward, which it said was an unsuitable environment to effectively care for patients at risk of clinical deterioration.
The report also found ineffective clinical governance at the hospital to ensure clinical staff competence, the development of treatment guidelines and to ensure the robustness of team-working arrangements among different staff disciplines.
Performance indicators, the report said, did not focus on patient outcomes.
The HIQA report stresses that there has been an inability in the health system to apply system-wide learning from previous adverse events.
Minister Reilly promised to implement the recommendations in the report.
[Posted: Wed 09/10/2013]