Savita hospital defends record
"This patient presented at 17 weeks gestation with back pain and subsequently underwent PROM (premature rupture of membranes) on the next day after admission. She developed signs of severe sepsis and septic shock four days after admission. She miscarried and was transferred to ICU. Thereafter, she developed serious multiorgan failure and died on the eighth day following admission to hospital."
This is the terse account of the death of Savita Halappanavar in October of last year, as detailed in the newly-released 2012 annual clinical report of the Women and Children's Directorate at University Hospital Galway (UHG) and Portiunciula Hospital, Ballinasloe. The directorate includes the maternity department at UHG.
The report, released to irishhealth.com, chronicles the death of Savita, and sympathises with her family.
It also gives a positive assessment of the overall performance of the UHG maternity unit in 2012 and defends its clinical results.
However, two independent review reports and a coroner's inquest this year have criticised maternity services at the hospital in the wake of Savita's death.
The new report, which details clinical activity in the maternity and paediatric units at UHG and Portiuncula Hosptal, Ballinasloe last year, says it was encouraging to see that key performance indicators (KPIs) drawn up for the Women and Children's Directorate at the two hospitals, along with Roscommon Hospital, have been turning 'green from red, thereby demonstrating the improvements in the service'.
Savita's death is included in the section of the report on severe maternal morbidity - cases where pregnant women were seriously ill. She is one of two sepsis cases in this section of the report. In the other sepsis case, the mother had suspected meningitis or drug toxicity following delivery and made a good recovery, according to the report.
The ICU section of the report also notes the Savita case: "Unfortunately, there was one case of maternal mortality in ICU in 2012 secondary to severe sepsis."
The Pathology Department section of the report notes: "A stillborn fetus, delivered at 17 weeks, was examined in conjunction with death of its mother. This fetus showed no deformities or evidence of septicaemia."
Writing in the foreword to the report, Dr Geraldine Gaffney, clinical director of the Women's and Children's Directorate says: "In October last year the death of a young pregnant woman occurred at UHG. This devastating event, the first of its kind to have happened here for 17 years, shocked both staff and the public alike. We extend our sympathy to the husband and family of Savita Halappanavar. I am mindful of the tremendous effect that this tragic event had upon members of staff and the public that use our service. I am grateful to those who sent us expressions of support during this difficult time."
The report notes that there were 19 cases of serious maternal morbidity at UHG in 2012, including one death - that of Savita Halappanavar.
It says when comparing rates of serious maternal morbidity against national statistics compiled by the National Perinatal Epidemiology Centre (NPEC) report on serious complications of pregnancy, 'our findings are very similar.'
The report adds that maternal morbidity statistics for UHG in 2012 were similar to the figures collected and published for UHG since 2003.
"We are reassured that the rates of serious maternal complications at UHG are similar to those found nationally."
The report makes no mention of Savita Halapanavar's request for a termination being refused or of system failures or care deficits that may have led to Savita's death.
Dr Gaffney, in her foreword, says the report 'serves as a credit to all those who work within the Directorate and is a testament and record of all that we do'.
The section of the report on midwifery services at UHG states: "In 2012 we continued to strive for excellence in delivery of our service and making the journey as positive and fearless for our mothers and babies in our maternity unit and the parents and children in our paediatric unit. Quality is our goal on a daily basis and we have huge pride in our service."
The Health Information and Quality Authority (HIQA), in its report on Savita's death, published last month, stated:"The Authority identified, through a review of Savita Halappanavar’s healthcare record, a number of missed opportunities which, had they been identified and acted upon, may have potentially changed the outcome of her care."
"For example, following the rupture of her membranes, four-hourly observations including temperature, heart rate, respiration and blood pressure did not appear to have been carried out at the required intervals. At the various stages when these observations were carried out, the consultant obstetrician, non-consultant hospital doctors and midwives/nurses caring for Savita Halappanavar did not appear to act in a timely way in response to the indications of her clinical deterioration."
The HIQA review also said there was a general lack of provision of basic, fundamental care, including not following up on blood tests as identified in Savita's case, a failure to recognise that Savita Halappanavar was at risk of clinical deterioration, a failure to act or escalate concerns to an appropriately qualified clinician when Savita Halappanavar was showing the signs of clinical deterioration.
HIQA said: "The consultant, non-consultant hospital doctors (NCHDs) and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time. However, this did not happen."
The safety body said its investigation uncovered a series of failures in the management, governance and delivery of maternity services at UHG which were not consistent with best practice.
Deficits in Savita's care were also highlighted in the HSE review of the case chaired by UK obstetrician Sir Sabaratnam Arulkumaran and in the coroner's inquest earlier this year.
The Savita case is currently being considered by the regulatory bodies for doctors and midwives - the Medical Council and the Nursing and Midwifery Board.
The HSE West/North West Hospital Group is also reviewing the actions of all staff members who treated Savita Halappanavar. On the basis of this, the actions of individuals may be referred on an individual basis by the group to the Medical Council or the Nursing and Midwifery Board.
Health Minister Dr James Reilly has already referred the findings of the Arulkmaran report to the Medical Council and the Midwifery Board.
In addition, Savita's husband, Praveen, has begun legal action against UHG and the HSE.
The HSE and the hospital group has said a number of recommendations arising from the three investigations into Savita's death have already been implemented.
[Posted: Mon 18/11/2013]