SAVITA HALAPPANAVAR DIED on 28 October 2012 at University Hospital Galway. She was 17 weeks pregnant. The cause of death was recorded as severe sepsis, E.coli in the bloodstream and a miscarriage at 17 weeks.

Source: Niall Carson/PA Wire

The death of the 31-year-old dentist precipitated a huge rallying cry for changes to Irish law in respect of abortion.

Her name is not only a household one, it has become commonplace in continued debates about the Eighth Amendment to the Constitution.

Investigations into her death did not specifically examine whether Article 40.3.3 had any act or part in her illness but two of the three recommended further scrutiny of the law of the day.

How then did a much-wanted pregnancy end in heartbreak for one family and launch Ireland into another period of reflection around abortion – an issue that had already divided the country for three decades?

The pregnancy

Savita found out she was pregnant in August 2012. She visited her GP and was referred to the antenatal clinic in UHG for care. It was her first pregnancy and she was due on 20 March 2013.

She had no risk factors or past medical problems.

On 11 October she went to UHG for her first routine antenatal visit. She was 15 weeks and five days into her pregnancy. The findings of all her exams were normal. She told staff that she wished to breastfeed and was given advice. A complaint about back pain led to a referral to a physiotherapy service.

A fetal anomaly scan was booked and she was scheduled for her next antenatal clinic on 3 December 2012, when she would have been at 23 weeks gestation.

Her death

However, on Sunday 21 October 2012 at 9.35am, Savita and her husband Praveen attended the gynaecology ward at UHG without appointment. She presented with intermittent lower backache.

UHG Source: Brian Farrell/Photocall Ireland

She was assessed and a treatment plan for back pain put in place. She left the hospital but was told by a doctor to come back in if she had any concerns.

Later that day – at about 3.30pm – she did return. She was upset and crying after having “felt something coming down”, which she had pushed back in.

A midwife working in the ward believed she was miscarrying and doctors were brought in to review the case.

By then, Savita was distressed and in unbearable pain.

The doctors on the ward believed that she was in the middle of a miscarriage – or about to miscarry. They noted that pregnancy loss was both inevitable and impending. They ruled out being able to perform what is known as a rescue cerclage (stitching the cervix closed to prevent miscarriage and allow a pregnancy continue to foetal viability).

The Halappanavars were moved to a single room to allow them their privacy during this devastating episode.

During that Sunday, doctors checked for a fetal heartbeat, which they were able to detect. The plan was to wait for the natural outcome of events.

Just after midnight on Monday, 22 October, Savita began vomiting violently and had a spontaneous rupture of membranes – that is that the bag of membranes around the foetus had burst and the fluid (also known as liquor) had leaked out.

By 8.20am, she was experiencing bleeding but her pain had eased. At this time, the consultant discussed the risk of infection and sepsis with her, explaining the need to continuously check for a fetal heartbeat.

At the same time the following day – Tuesday, 23 October – Savita and Praveen asked about using medication to induce the inevitable miscarriage. According to the HSE report published after her death, they told the consultant they did not want a protracted waiting time when the outcome was inevitable.

They were advised of Irish law in relation to this request with the consultant recalling saying:

Under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heart[beat].

The clinical plan to “await events” remained and Savita continued to be administered antibiotics while being examined throughout the day. She complained of ‘weakness’ during this time but was eating and drinking normally.

Praveen continued to stay with her through the days – and overnight on a camp bed.

At 4.15am on Wednesday 24 October, a midwife noted that Savita was feeling cold and shivery (the radiator in the room did not work and was documented as being “stone cold”). Both she and her husband asked for extra blankets and the midwife noticed Savita’s teeth were chattering. She was given paracetamol to manage her increased temperature.

By 7am, Savita was suffering from nausea and vomiting. Just over an hour later, the consultant’s team diagnosed chorioamnionitis (an inflammation of the fetal membranes due to infection). Their focus was to find the source of that infection and to give time for the prescribed medications to work.

The plan at this point was for Savita’s vital signs and fetal heart rate to be monitored. She was to be reviewed later with a view to induce labour once there was no fetal heartbeat present.

By 11.45am, the fetal heart had been checked and was still 148 beats per minute (within normal range).

Savita, by lunchtime, was also complaining of chest pain and had difficulty breathing.

Nurses had noted a sudden deterioration of her condition at about noon, and she was “very unwell” by 1.20pm.

Following a review by the consultant team, Savita was diagnosed with septic shock, with chorioamnionitis being considered as the cause.

After 2pm, the plan of treatment was noted to include a dosage of misoprostol, a drug used to induce delivery. However, it was never administered as there was a spontaneous delivery at 3.15pm in theatre, where she had been brought to have a central line inserted.

Praveen was taken into the operating theatre to be with his wife who was extremely upset about the miscarriage.

Savita was then transferred to the High Dependency Unit of the hospital.

Overnight, into Thursday 25 October, her condition continued to deteriorate. She needed increased oxygen and was transferred to the intensive care unit (ICU) at 3am.

She remained critically ill throughout the coming days. She was intubated, ventilated and her cardiac output was decreasing by Friday afternoon.

Despite ongoing measures by the ICU medical staff through to Saturday, Savita remained in critical condition – and deteriorating.

At 12.45am on Sunday, 28 October, Savita suffered a cardiac arrest.

At 1.09am – almost a full week from her presentation to the hospital – she was pronounced dead.

It was the first direct maternal death to happen at University Hospital Galway in 16 years.

Media reports and the outcry

Just over a fortnight later, Kitty Holland in the Irish Times wrote about Savita’s premature death under the headline Woman ‘denied a termination’ dies in hospital.

Source: Mike Hogan/Twitter

The journalist outlined how two investigations were underway to examine how a dentist who presented with back pain ahead of a miscarriage died of septicaemia a week later.

In that initial article, Praveen Halappanavar speaks of how he and his wife asked multiple times for a medical termination but were told that “this is a Catholic country”.

The story was reported across every outlet in Ireland, dominated the political agenda of the coming weeks and made headlines across the world.

On 16 November, the main story on the India Times website was run under the headline Ireland Murders Pregnant Indian Dentist.

Reporters spoke to her heartbroken husband and father.

Immediately, calls were made for changes to Ireland’s abortion laws. At that time, the X Case still had not been legislated for. (See more on that here.)

Within days, vigils and protests were organised across the country. Thousands of people lit candles, held photographs of Savita with the words ‘Never again’ and ‘She had a heartbeat too’ written beside her face and demanded the government to act.

A candlelit vigil at St Stephen's Green in Dublin Source: Niall Carson/PA Wire

It was a catastrophe that gave power to the abortion rights movement.

About four weeks previously, the first March for Choice had been held in Dublin with a few thousand in attendance.

Dozens of those same groups that mobilised massively during the aftermath of Savita’s death eventually joined together under the Coalition to Repeal the Eighth Amendment umbrella.

The inquest

The inquest into Savita Halappanavar’s death was held between 15 and 19 April 2013 at Galway Coroner’s Court.

Midwives, doctors, specialists, consultants and friends of the victim all gave evidence as witnesses. Another 70 statements from hospital staff and other sources were also gathered for the proceedings.

Praveen attended four of the five days, despite finding the process very stressful.

Praveen outside the Coroner's Court in Galway Source: Laura Hutton/Photocall Ireland

An inquest’s remit is to determine the facts of a death, not to find culpability.

During the hearing, one of the midwives who cared for Savita admitted that she mentioned Ireland being a Catholic country in an attempt to explain why doctors could not expedite her miscarriage.

While being questioned on the Wednesday of proceedings, she said the phrase had “come out the wrong way” and that she was sorry she said it.

“It does sound very bad now, but at the time I didn’t mean it that way.

I was trying to be as broad and explanatory as I could. It was nothing to do with medical care at all.

The coroner Dr Ciarán McLoughlin said the remark had been picked up around the world but stated Irish public hospitals did not operate under religious dogma of any persuasion.

The coroner also heard from a consultant obstetrician about the requests made by the Halappanavars for a termination. She said she was dealing in probabilities and had not established the life was at risk until Wednesday 24 October.

The coroner was critical of the obvious systems failures in the hospital’s care of Savita, as well as the inclusion of backdated entries in her medical records. Many of the notes on her file were added days, and in some instances, two weeks after her death. They were, as a consequence, hard to follow.

On Friday 19 April 2013, after two hours and 45 minutes of deliberations, the 11-person jury returned a unanimous verdict of medical misadventure.

A verdict of medical misadventure does not infer criminal or liability. It is also not cause of death. The cause of death was septic shock, E.coli in the bloodstream and a miscarriage at 17 weeks.

Praveen with his legal team outside the coroner's court in Galway Source: Laura Hutton/Photocall Ireland

The jury on that day also “strongly endorsed” Dr McLoughlin’s nine recommendations, each of which they considered individually.

The first recommendation dealt with the laws surrounding terminations in Ireland. It read:

You may recommend that the Medical Council lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which will remove doubt and fear from the doctor and also reassure the public. An Bord Altranais should have similar directives for midwives so that the two professions always complement one another.

Making comment on the topic, Dr McLoughlin said, “It is not for the court to advise the Oireachtas but they may take cognisance of these proceedings.”

He also described current Medical Council guidelines on abortion as “very brief” and said they should be enhanced. He added that doctors practising in good faith “should not have to labour under the threat” of sanctions as serious as removal from the medical register or prison.

During the inquest, a number of witnesses including Savita’s consultant, said that if it was legally permissible to offer the patient a termination earlier than when it was given, she would probably be alive today.

The HSE report

The terms of reference for the Health Service Executive’s investigation into Savita’s death were quickly agreed by 19 November 2012. That probe, as well as an internal one by the hospital itself, was already under way before the case was made public by the Irish Times.

Sir Sabaratnam Arulkumaran, Professor Emeritus of Obstetrics and Gynaecology at St George’s University of London, was tasked with being its external independent chairperson.

Professor Sir Sabaratnam Arulkumaran Source: Sam Boal/RollingNews.ie

The investigation was completed on 7 June 2013.

Across 108 pages, it outlined how there was a “lack of recognition of the gravity of the situation and of the increasing risk to the mother which led to passive approaches and delays in aggressive treatment”.

Professor Arulkumaran and his six-person team said this appeared to have been “either due to the way the law was interpreted in dealing with the case or the lack of appreciation of the increasing risk to the mother and the earlier need for delivery of the fetus”.

The law mentioned here refers to Article 40.3.3 of the Constitution which equates the unborn’s right to life to that of its mother.

The investigation team “strongly” recommended and advised for the law of the day to be “considered” by the Oireachtas and others, up to and including “any necessary constitutional change”.

The report found that the treatment plan for Savita to “await events” was in place from 21 October to the morning of 24 October.

This would be appropriate as long as there is not a risk to the mother or fetus, the foreword to the report explains.

However, if correct monitoring and evaluation of Savita’s condition had been carried out, the clinical team would likely have reconsidered the need to expedite delivery, the investigators concluded.

Delaying such treatment can, on occasion, be fatal, they said. And in this situation, it was.

Savita’s doctors made it clear to the investigation team that the plan to ‘await events’ was made because of their interpretation of the law related to pregnancy termination.

During an interview with one of the consultants on the case, investigators heard that “under Irish law, if there’s no evidence of risk to the life of the mother, our hands are tied so long as there’s a fetal heartbeat”.

The consultant went on to state that if risk to the mother was to increase, a termination would have been possible, but that it would be based on actual risk and not a theoretical risk of infection [as] “we can’t predict who is going to get an infection”.

There is a difficulty in interpretation of law in relation to ‘what constitutes a potential major hazard or threat to a mother’s life’, the investigation team heard from consultants.

This needs clarification, they wrote.

The consultant clearly thought that the risk to the mother had not crossed the point where termination was allowed in Irish law on the morning round on the 24 October.

The option was eventually discussed by the team that afternoon, three days after Savita had been admitted.

However, she delivered spontaneously about two hours later.

The investigation found three key causal factors in Savita’s death, including:

that there was inadequate assessment and monitoring of Savita, and that the clinical team failed to devise and follow a plan of care

there was of Savita, and that the clinical team failed to devise and follow a plan of care the failure to offer all management options to Savita

to Savita a non-adherence to clinical guidelines related to the prompt and effective management of sepsis, severe sepsis and septic shock when it was diagnosed.

The investigation made nine recommendations in total. Recommendation 4b reads:

“There is an immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgement can be exercised in the best medical welfare interests of patients. There is a parallel immediate requirement for clear and precise national clinical guidelines to meaningfully assist the clinical professionals who have the responsibility, often in circumstance of rapid deterioration or emergency, as to how to exercise their clinical professional judgement in a particular case.

We recommend that the clinical professional community, health and social care regulators, and the Oireachtas consider the law including any necessary constitutional change and related administrative, legal and clinical guidelines…

“These guidelines should include good practice guidelines in relation to expediting delivery for clinical reasons including medical and surgical termination based on available expertise and feasibility consistent with the law.

We recognise that such guidelines must be consistent with applicable law and that the guidance so urged may require legal change.

Delving into the causal factors more deeply, the HSE report says that in cases of preterm pre-labour rupture of the membranes where signs of sepsis occur, best practice guidelines promote that delivery is expedited. However, there are no clear guidelines accepted at local, national or international level on the management of miscarriage with prolonged rupture of the membranes.

The report deduces the reason for that to be because “clinical practice in other jurisdictions would have led to an early termination of pregnancy in equivalent clinical circumstances”.

Professor Arulkumaran recommended such guidelines be developed but to allow for same, legal change may be required.

Candles are left outside Leinster House in Dublin, 17 November 2012 Source: Niall Carson/PA Wire

Writing more frankly about the law later in the report, the team said one of the key causal factors in Savita’s death was a failure to offer all management options to the patient.

The investigators said they were “satisfied that concerns about the law, whether clear or not, impacted on the exercise of clinical professional judgement” in this case.

Although they said they did not have a remit to carry out a legal review of the law in Ireland, they said that there were legislative factors which affected medical considerations. They wrote:

Fetal demise is certain in an inevitable miscarriage at 17 weeks where there is spontaneous rupture of the membranes and infection in the uterus. The risks to the mother can be reduced by expediting delivery. Continuation of the pregnancy is putting the mother at increasing risk with no potential benefit to mother or fetus.

“International best practice includes expediting delivery in this clinical situation… because of the risk to the mother if the pregnancy is allowed to continue. Expediting delivery (either medically or surgically as appropriate or feasible, and within the law) at the earliest sign of infection in the uterus is a critical part of management to reduce the risk of progression to sepsis, severe sepsis and septic shock and maternal morbidity and death.

The records and interviews confirmed that – from the time of her admission [21 October at about 3.30pm], up to the morning of 24 October, the management plan for the patient was to ‘await events’ and to monitor the fetal heartbeat in case an accelerated delivery might be possible once the fetal heart stopped. The interviewees stated to the investigation team that this was because of their interpretation of the law related to pregnancy termination.

“Different management options needed to be considered – including termination of the pregnancy – as removal of the source of infection reduces the potential risk of sepsis thereby potentially avoiding rapid deterioration in the patient’s clinical condition due to progression to severe sepsis and septic shock with an associated high mortality rate.”

The investigation team was also of the opinion that there was an “over-emphasis on the need not to intervene until the fetal heart stopped” along with “an under-emphasis on the need to focus appropriate attention on monitoring and managing the risk of infection and sepsis in the mother”.

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 investigators warned that similar incidents could happen again if clarity as to the law and national guidelines remained absent.

The HSE report wasn’t just critical of the law, and the doctors’ interpretation of same. It noted the patient was not monitored as frequently as she should be, that there was inadequate assessment which would have allowed the consultants to recognise the signs of infection and that there was a non-adherence to guidelines for the prompt and effective management of sepsis, severe sepsis and shock.

The HIQA report

There was to be a third inquiry stemming from this tragedy.

The Health Information and Quality Authority (Hiqa) is tasked with the oversight of Ireland’s healthcare delivery and so was asked to investigate the care delivered by the HSE to patients, including pregnant women, at risk of clinical deterioration “including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar”.

It had a broader remit to look at wider implications, as well as the specifics of the case.

It did not deal with the legal situation of the time, and did not mention the doctors’ interpretation of the law, the Constitution or the Eighth Amendment.

Director of Regualtion at HIQA Phelim Quinn Source: Sam Boal/RollingNews.ie

The damning 258-page document runs through the many failures of the hospital “in the provision of the most basic elements of patient care to Savita Halappanavar and also the failure to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner”.

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In summary, Hiqa said of the care provided to the Indian-born dentist there was a:

General lack of provision of basic, fundamental care, for example, not following up on blood tests

Failure to recognise that she was at risk of clinical deterioration

Failure to act or escalate concerns to an appropriately qualified clinician when there were signs of clinical deterioration.

The watchdog detailed 13 specific times in the seven days where there were opportunities missed that could potentially have saved her life.

Source: HIQA

The authors were highly critical about the care given at each of these moments over the seven days. From the outset, Hiqa said an elevated white cell count should have alerted staff to investigate further. It also outlined, as did the HSE report, that the hospital’s Maternal Obstetric Early Warning Score chart was not in use on this particular ward.

On the plan of care to “await events” put in place at 8.20am on Monday, 22 October, Hiqa said that “a more comprehensive plan of care should have been developed and documented” at this time. It should have contained elements to address and investigate the fact that infection was the most probable cause of the inevitable miscarriage and that the rupture of membranes increased the risk of infection.

Hiqa explained that ‘await events’ refers to the conservative management of miscarriage as opposed to the surgical or medical management of miscarriage.

Another review by a doctor on Wednesday, 24 October between 6.30am and 7.50am was also recorded as a missed opportunity to change Savita’s treatment plan, despite a discussion between a junior doctor and a more senior one.

Hiqa’s subsequent recommendations did not just focus on Galway – but all maternity wards in Ireland. It emphasised a need to “review and improve maternity services in respect of the management of sepsis, clinically deteriorating pregnant women, patient choice, models of care and providing a suitably skilled and competent workforce that can deliver safe and effective care at any given time”.

Apologies

Following the publication of the Hiqa report, University Hospital Galway apologised to Praveen Halappanavar.

Nine members of staff who were involved in Savita’s care were disciplined by their employer. A further 21 people were found to have had “no case to answer”.

In 2016, Praveen settled a medical negligence case taken against the HSE just three days before a hearing was due to start in the High Court.

He now lives outside of Ireland.

Protection of Life During Pregnancy Act 2013

Men and women across the world were both touched and angered by Savita’s death. It led to rallies, protests and demands for new legislation in Ireland. At the very least, activists wanted the government to legislate for the X Case.

When working out the Programme for Government after the 2011 election, Labour had received commitments from Fine Gael on the issue.

The coalition was already due to consider the Expert Review Group’s report (published in November 2012) following the European Court of Human Rights’ judgement in the case of A, B and C versus Ireland and Savita’s death compounded the pressure on Fine Gael to come good on those promises.

That court found that while women do not have an automatic right to an abortion, Ireland had violated the European Convention on Human Rights by not providing abortion procedures in line with the rights enshrined in the Constitution.

The legislative process began in January 2013 with Oireachtas committee hearings – just months after Savita’s death. The Health and Children Committee heard from medical and experts, as well as other stakeholders over three days.

President Michael D Higgins signed the Protection of Life During Pregnancy Bill 2013 into law on 30 July 2013.

The act legally gives a woman access to an abortion where there is a real and substantial risk to her life, including risk of suicide.

In short, it legislated for the X Case of 1992.

Today

An Oireachtas committee was again central to the process which has led to a referendum being held on the Eighth Amendment on 25 May.

Following the Citizens’ Assembly’s recommendation to allow for terminations up to 12 weeks of pregnancy with no restrictions, the Committee on the Eighth Amendment of the Constitution was set up.

It again brought in legal and medical experts over weeks of hearings in 2017.

One of those experts was Sir Arulkumaran – the author of the HSE report into Savita’s death. He mentioned her case during proceedings on 18 October.

“It was very clear to me during the inquiry that the thing preventing the physician from proceeding was the legal issue because she repeatedly said she was concerned about the legal issue. I will give a little bit of explanation,” he said.

The mother was sick. There was no question about that. Even at the last minute they were using a hand probe to see whether the baby’s heartbeat was present or not. Any junior doctor would have said it was a serious condition and they must terminate.

“They were just keeping her going because of the mere fact the heartbeat was there. The legislation played a major role in making a decision. Somebody else might say they would have done the termination much earlier. That is a personal interpretation. It is why things are made difficult because of the legislation.

“I agree that if the legislation had been different, Savita’s case would not have happened.”

The vote

The loss of Savita’s life (and that of her unborn child) was devastating to her family and those who loved her. It was a tragedy of heartbreaking proportions resulting from bad medical care exacerbated by doctors being asked to interpret the law as part of their day jobs.

Source: Laura Hutton/Photocall Ireland

Her name and face are known the country over. She left a mark on Ireland, its medical care and its laws. The circumstances of her death continue to be talked about in relation to the Eighth Amendment, and whether its existence or deletion could have changed those events of October 2012.

Three reports were made publicly available and disseminated the most intimate details of her last days. Two of them made clear that changes in law would be welcome. The other did not mention the Eighth Amendment or the Constitution.

From his experience of the journey from the camp bed in the labour ward of University Hospital Galway to Galway Coroner’s Court, Praveen Halappanavar said he hoped legislation would be enacted to ensure no woman would die in a similar way in Ireland again.

“It was the end of the world. She wanted to live, have babies… I still can’t believe that she’s not with us. We just can’t believe that in the 21st century something like this would happen,” he told RTÉ just weeks after he lost his wife.

Five months later, as he continued to fight for the truth to come out about her death, he thanked the Irish people for their support, telling the Guardian:

“It’s all for her, and maybe something out of this will be for good in the long run.”