Yesterday's report into the circumstances of Savita Halappanavar's death, has, not unexpectedly, added little in the way of fresh information that had not already emerged from the inquest into her death and a previously published HSE investigation. There were critical basic omissions in her care, including a failure to record her vital signs, which in turn led to a delay in the recognition of her clinical deterioration. Where the latest report cuts new ground is in charting the wider deficiencies in the health system, both in University Hospital Galway and nationally.
Deficits in care
The health watchdog has determined that there were deficits for maternity patients attending the hospital during core hours, involving patients not being initially assessed and receiving ultrasound tests in a timely manner. Patient healthcare records were not managed in line with the HSE's standards and recommended practices. Astonishingly, the National Maternity Health Care Record was not in use in at the hospital.
But it is at a national level that the report should send a shiver down the spine of every citizen. We are all potential patients of the State’s public hospitals and must be seriously concerned that, in essence, the Hiqa investigation team has uncovered several examples of corporate negligence by the HSE.
The finding that only five of the country's 19 maternity units/hospitals were able to provide a status report on the implementation of recommendations from an investigation with many similarities to the Halappanavar case is utterly damning. The other investigation with similarities was into the death of Tania McCabe in 2007 at Our Lady of Lourdes Hospital in Drogheda, after delivering twins – one of whom also died. The pathologist concluded cause of death was as a result of multiorgan failure and post-partum haemorrhage due to sepsis.
The HSE reported that the McCabe recommendations were implemented at a local HSE level with regional HSE oversight. But when it looked for evidence, Hiqa found “only five of the 19 hospitals/units were able to provide a detailed status update on the implementation of recommendations”.
Remember the 2006 Lourdes hospital inquiry into the Caesarean section rates of Michael Neary, consultant obstetrician at Our Lady of Lourdes Hospital in Drogheda? It recommended that annual clinical reports of activity and clinical outcomes should be prepared and published within nine months of the previous year's end. During this investigation, Hiqa found that, some seven years later, eight of the 19 units do not produce any form of annual clinical report.
A key paragraph in yesterday’s report says: “The lack of a nationally co-ordinated approach to the implementation of the recommendations of the HSE inquiry into the death of Tania McCabe, the lack of local governance arrangements to ensure that recommendations as applicable to their particular service are implemented, and the ambiguity regarding who has the overall ownership of and responsibility for implementing the National Clinical Care Programmes again raises a fundamental and worrying deficit in our health system.”
Future harm
In other words, the inability of HSE management to implement important changes arising from adverse patient events in a timely manner means that, despite being aware of specific risks, it is failing to take actions that will prevent future harm and even death to patients.
It is now time for senior HSE managers to face rigorous scrutiny, and where appropriate, meaningful sanctions for their inaction.