Yesterday's proceedings at the inquest into the death of Savita Halappanavar were largely taken up with evidence from intensive care unit doctors and nurses who looked after her from Wednesday, October 24th, until her death the following Sunday.
Praveen Halappanavar, through his counsel, said he would be extremely grateful to his "dying day" for the care given to his late wife by the ICU team. Listening to the evidence subsequently given by specialist nurses and doctors, it was apparent why he offered such heartfelt gratitude.
A picture of co-ordinated and highly professional care quickly emerged. Consultant anaesthetists, the specialists who provide intensive care, formally handed over Savita’s care to one another at 9 am and 5pm each day.
A complex range of both invasive and non-invasive treatments were given to Savita, including a cocktail of drugs designed to keep her blood pressure above a critical level.
Lactic acid levels in her blood were closely monitored. These provide a good indication as to whether there is adequate blood flow to all parts of the body; as the levels rise, it is a sign that insufficient oxygen is reaching the tissues.
ICU nurses also described giving highly co-ordinated care to her. Staff nurse Jacinta Gately gave evidence of her patient's last hours and was visibly moved as she described attempting to resuscitate Savita just before she passed away.
Later, consultant microbiologist Dr Deirbhile Keady described how blood cultures help to guide the antibiotic treatment of a patient with severe sepsis.
Within seven hours, the first indications of what type of bacteria is causing the infection emerge, although it takes an overnight “cooking” of the blood sample before an exact identification is possible.
However, she explained that protocols indicated the precise antibiotics to be given before the exact bug has been identified. In Savita's case, she said the initial dose of antibiotics had been at least partially effective.
Asked by counsel how unusual it was to find the E.coli ESBL microbe in an obstetric setting, Dr Keady said it was a very uncommon finding in a blood culture taken from a pregnant woman. There was some debate about whether the transfer of the first blood culture sample from the ward to the laboratory had been substantially delayed, with coroner Dr Ciarán MacLoughlin observing that if this was the case, it would represent an additional risk for Savita.
As the first week of the inquest draws to a close, among the medical issues that remain to be resolved are:
Was the hospital protocol for the management of sepsis followed fully?
Had an early warning score (EWS) system been in operation in the obstetric unit during Ms Halappanavar's admission, would this have allowed her consultant, Dr Astbury, to perform a termination earlier?
How rare is the E.coli ESBL bacterium in Ireland ? Is it an aggressive microbe and how successful is standard antibiotic therapy in eradicating it?