A unanimous verdict of death by medical misadventure was returned at the inquest into the death of Savita Halappanavar (31) in Galway yesterday. The 11-member jury also endorsed nine recommendations put forward by coroner Dr Ciaran MacLoughlin.
Earlier, in his summing up, Dr MacLoughlin charted the decline of a “vibrant young woman”, the litany of failures in her medical care at University Hospital Galway and the lack of any substantial intervention until she was “in peril of her life”.
Dr MacLoughlin described how Savita self-referred to the gynaecology department at the hospital on the morning of Sunday, October 21st, with severe back pain. It was discovered she was losing her 17-week pregnancy.
“A blood test at presentation showed an elevated white cell count of 16.9 indicating the possibility of infection. The abnormality was not accessed until 17.24 the following day. If it had been recorded in the notes or conveyed to Dr Katherine Astbury it would have been repeated,” said Dr MacLoughlin.
Consultant
Savita was first seen by her consultant Dr Katherine Astbury at 8.20 am on Monday, October 22nd. She was again reviewed by Dr Astbury at 8.20 the following morning.
“Ms Halappanavar requested a termination of the pregnancy to expedite a naturally occurring process. Dr Astbury explained it was illegal in Ireland to terminate a pregnancy unless there was a real and substantial risk to the life of the mother. At that time there was no real or substantial risk to her life.”
At 4.15 on the morning of Wednesday, October 24th, Ms Halappanavar was feeling cold and shivery. Her temperature was elevated at 37.7. The attending nurse formed the opinion that she was cold and gave her paracetamol to reduce her temperature. Her teeth were chattering. Neither pulse nor blood pressure were recorded.”
Blood tests
Bloods were taken but the serum test which should have been done on the ward was sent to the lab and there was no request that the blood tests be done urgently.
“At 08.25 [on Wednesday] Dr Astbury attended Ms Halappanavar . It appears the urgency of her condition was not conveyed to Dr Astbury,” said Dr MacLoughlin.
“Dr Astbury was phoned at 13.00 hours and informed Savita’s condition had deteriorated rapidly. Dr Astbury spoke to a consultant colleague who advised she should seek the opinion of the clinical director before proceeding to deliver the foetus. At this time her bp [blood pressure] was 60/30. She was in peril of her life.”
A scan at 2pm showed the foetus had died and Savita was taken to theatre where a female foetus delivered spontaneously.
“She was subsequently transferred to the High Dependency Unit where she received fluid, haemodynamic resuscitation and antibiotics. She continued to decline and was transferred to the ICU on October 25th at 3.15 am, where she remained critically ill. She developed adult respiratory distress syndrome, disseminated intravascular coagulation, multi-organ failure which failed to respond to treatment and despite the valiant efforts of the doctors and nurses in ICU the life of this vibrant young woman ebbed away. She had a cardiac arrest and was pronounced dead on October 28th.”
