Savita died at Galway University Hospital on 28 October last year from septic shock when she suffered a miscarriage. The HSE had commissioned investigation into her death. The review report was released last night.
The report says that hospital guidance assumes that there would be four-hour monitoring of patient observations for patients with premature rupture of membranes.
In the case of Savita Halappanavar, the monitoring was less frequent.
From the time of her admission, up to the morning of October 24, the clinical management plan for the patient centred on the approach to "await events" and to monitor the foetal heart in case an accelerated delivery might be possible, once the foetal heart stopped.
The report says that awaiting events is clinically appropriate - provided it is not a risk to the mother or the foetus.
It concludes that proper monitoring and evaluation of the changing clinical presentation along with investigations would likely have lead to reconsideration of the need to expedite delivery.
Delay was fatal
Delaying adequate treatment, including expediting delivery in such situations, can be fatal.
The review committee head and renowned UK professor Sabaratnam Arulkumaran said the issue "is not one single mistake but a series of problems which we have identified and put in a number of recommendations so that such an incident does not happen again in any other hospital or to any other woman.''
He said: "''The white cell count was elevated (when examined) on admission and this was not repeated, and when the membranes rupture it has to be done every four hours, it was not done, and even when the pulse rate went beyond 100, they should have checked it more frequently and ordered some blood tests to find out whether its infection and none of this was carried out.''
The chairman of the clinical inquiry into the death of 31-year-old Savita revealed that he would have ended her pregnancy when she showed initial signs of the fatal infection.
Gravity of situation ignored
"The gravity of the situation was increasing but appears not to have been recognised and acted upon," the report found. "Awaiting the blood results and not fully appreciating the deteriorating and complex clinical situation missed an opportunity for early and appropriate intervention with the help of multidisciplinary input."
The review team highlighted a litany of failings that made a significant contribution to her death, including the interpretation of Ireland's strict abortions laws that only allows termination when there is a real and substantial risk to a woman's life; that staff did not adequately assess and monitor Savita as an infection took over her body; and that she was not offered all management options including termination.
They also found clinical guidelines relating to the prompt and effective management of sepsis at Galway University Hospital were also not followed, which includes removing the source of an infection.
The 108-page report provides a detailed chronology of events from October 21 till her death and says that:
- Lack of recognition of the increasing risk to her life.
- Delays in aggressive treatment.
- Failure to adhere to sepsis management guidelines.
- Maternity Early Warning Score Chart system recommended.
- Mandatory induction and education of sepsis management.
Termination not offered
The review concludes this appears 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 the delivery of the foetus.
It also says that when Savita and her husband Praveen inquired about the possibility of having a termination of pregnancy, this was not offered or considered possible by the clinical team until the afternoon of October 24, due to their assessment of the legal context in which their clinical professional judgement was to be exercised.
With inputs from agencies