University Hospital Galway failed to provide Savita Halappanavar with "the most basic elements of patient care" and failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner, according to a report by the State's health watchdog.
The report by the Health Information and Quality Authority into Ms Halappanavar’s death last year points to 13 “missed opportunities” which, had they been identified and acted upon by the hospital, “may potentially have resulted in a different outcome for her”.
Among the missed opportunities listed in the report are a failure to carry out the recommended four-hourly observations of her temperature, heart rate and blood pressure and a failure to follow up blood tests.
“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.”
Clinical findings
It says the most senior clinical decision maker involved in the provision of care to Ms Halappanavar at any given time should have been suitably 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."
It says the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Ms Halappanavar did not appear to act in a timely way in response to her clinical deterioration and the report is critical of 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 257-page report from Hiqa is the third report into the death of Ms Halappanavar, and follows a coroner’s inquest and an inquiry by the HSE.
In addition, the report says 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, the gynaecology ward in which Ms Halappanavar was accommodated.
The report points out that the Galway hospital developed a local Modified Obstetric Early Warning Score chart in 2009 but this was not in use on the ward three years later, in October 2012.
No formal protocol
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 Ms Halappanavar’s “tragic event”. It says there is a “disturbing resemblance” between the case of Ms Halappanavar and that of Tania McCabe and her son Zach, who died in 2007 after developing sepsis when her membranes ruptured.
Only five of the country’s 19 maternity hospitals were able to provide Hiqa with a detailed status update on the implementation of recommendations from the Tania McCabe report.
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.
According to Hiqa, eight maternity units do not produce any form of annual clinical report, as recommended by the 2006 Lourdes hospital inquiry.
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 immediately to undertake a review of maternity services.
The authority says maternity services need to be improved in relation to managing sepsis and clinically deteriorating pregnant women, patient choice and in the provision of a suitably skilled and competent workforce to deliver safe care.
Inconsistent recording
The report reveals wide variations in clinical care across different hospitals and units. It says there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, and no centralised approach to reporting maternal morbidity and mortality.
As a result, it is impossible to assess properly the performance and quality of maternity services nationally, according to the report.
The Department of Health should develop a code of conduct for employers setting out their responsibilities on safety and performance, it says. This would clearly articulate the duties and responsibilities on them in regulating staff, including referral of professionals to regulatory bodies.
Hiqa wrote to HSE director general Tony O’Brien several times this year seeking assurances in relation to the care of clinically deteriorating obstetric patients.
Mr O’Brien responded to the authority, providing assurances on care in many hospitals, but Hiqa says it remains concerned that the assurances were not in place for every hospital providing maternity services.
