A new report into the death of Savita Halappanavar has found there was a failure to provide her with the most basic element of patient care and a failure to recognise and act upon signs of her clinical diagnosis in University Hospital Galway last year.

The report by the Health Information and Quality Authority points to a number of “missed opportunities” which, had they been identified and acted upon, could have saved her life.

Nationally, it warns that maternity services may, on occasion, not be as safe as they should be, or of sufficient quality. The report says this must be addressed as a matter of urgency and it calls on the HSE and the Department of Health to immediately undertake a review of maternity services.

It says the consultant obstetrician, non-consultant hospital doctors and midwives/nurses caring for Ms Halappanavar did not appear to act in a timely way in response to her clinical deterioration and identifies a failure to act or escalate concerns to “an appropriately qualified clinician”.

Ms Halappanavar, who was 17 weeks pregnant, died in the hospital of sepsis last October 28th following a miscarriage.

The Hiqa report says the recommended four-hourly observations of her temperature, heart rate and blood pressure did not appear to have been carried out at the required intervals. It also pointed to a failure to follow up on blood tests for Ms Halappanavar.

“The consultant, NCHDs and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time,” according to the report. “However, this did not happen.”

It says the most senior clinical decision maker involved in the provision of care to Ms Halappanavar at any given time should have been suitable clinically experienced and competent to interpret clinical findings and act accordingly. “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”

In addition, the clinical governance arrangements within the hospital failed to recognise that vital hospital policies were not in use, nor were arrangements in place to ensure the provision of basic patient care on St Monica’s Ward, where Ms Halappanavar was accommodated.

The report points out that UHG had developed a local Modified Obstetric Early Warning Score (MOEWS) chart in 2009 but this was not in use on the ward three years later, in October 2012.

Summary

It says there was no formal clinical escalation protocol and no emergency response team in place at the hospital and while sepsis guidelines were in place, clinical governance arrangements were “not robust enough” to ensure they were adhered to.

The report says it is critically important that the health service learns from mistakes, including this tragic event. However, it points out there is a “disturbing resemblance” between the case of Ms Halappanavar and that of Tania McCabe and her son Zach, who died in 2007.

There are 34 recommendations in the report, starting with a call for their full implementation. In addition, it says the HSE and the Department of Health must as a priority review maternity services nationally.

The 250-page report from the Health Information and Quality Authority is the third report into the death of Ms Halappanavar in University Hospital Galway last year, and follows a coroner’s inquest and an inquiry by the HSE.

The long-awaited report was presented to the Hiqa board on Monday evening and a copy was furnished to Minister for Health James Reilly yesterday. Ms Halappanavar’s husband Praveen, who did not cooperate with the inquiry, is also being furnished with a copy of the report through his solicitor.

The terms of reference of the Hiqa report were “’to investigate the safety, quality and standards of services provided by the HSE to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway (UHG) and as reflected in, among other things, the care and treatment provided to Savita Halappanavar”.

Dr Reilly again expressed his sincere sympathy to the Halappanavar family for theloss of Savita.

“This tragedy should not have happened. The untimely death of Savita

Halappanavar on 28th October last year was a shocking wake-up call to the

whole healthcare system about how failures in patients’ care can sometimes

have extreme consequences.”

He said:“I am determined that out of the sad loss of this young

woman our whole health system will learn lessons that will ensure that it

provides safe, patient-centred care.”

The Minister also said he would ensure that the report would be given careful

consideration and reflection to ensure all of its findings and

recommendations are responded to.