Medical practitioners will receive special training in the recognition and management of sepsis in order to prevent serious infections similar to that which led to the death of Savita Halappanavar.
The Health Service Executive (HSE) report into Ms Halappanavar's death published yesterday found there was inadequate assessment and monitoring to pick up the deterioration in her condition, a failure to adhere to hospital guidelines for managing sepsis and a failure to offer her all management options as she experienced inevitable miscarriage.
A lack of recognition of the gravity of the risk to her health led to “delays in aggressive treatment”.
UK-based obstetrician Prof Sir Sabaratnam Arulkumaran, who led the inquiry team, called on the Government to change the law to help doctors treating pregnant women who have rapidly escalating conditions such as sepsis, which caused Ms Halappanavar's death.
The HSE's national director of quality and patient safety Dr Philip Crowley said Ms Halappanavar's death from sepsis was a "rare occurrence", and it was clear from the HSE report that "staff did not recognise what was happening".
"Sepsis is becoming more common. As a health service we need to redouble our efforts to train people in the recognition and very aggressive management of sepsis and that is what we are going to do," he told RTÉ's Morning Ireland.
Questions were raised yesterday about staffing levels at Galway University Hospital in the days leading up to Ms Halappanavar's death, but Dr Crowley said the hospital had since confirmed that the wards caring for her had been adequately staffed and no consultant obstetrician was on leave at the time.
Treatment provided by University Hospital Galway, where Ms Halappanavar died last October after being admitted when 17 weeks pregnant, was heavily criticised by the HSE inquiry team.
The report warned more women could die in Irish hospitals in a similar manner unless legal clarity is provided for doctors on when they can intervene to terminate a pregnancy.
Dr Crowley said today that medical practitioners would need clear instructions on how to implement any forthcoming legislation on abortion.
“No matter what law is passed by the Oireachtas we will need clear clinical guidance as to how to apply that law intelligently and safely and carefully in the care of a whole myriad of different clinical situations.”
Minister for Health James Reilly expressed has referred the HSE report to the Medical Council and the Nursing and Midwifery Board of Ireland for consideration. He has also invited the Institute of Obstetricians to meet him for talks on its implications.
The hospital and HSE apologised to Ms Halappanavar’s husband Praveen yesterday for the events in her care that contributed to her tragic death and sought to reassure the public they had made changes to ensure the circumstances of her death were not repeated.
Galway University Hospital is awaiting the outcome of a third report by the Health Information and Quality Authority before bringing recommendations to the board about disciplinary measures, clinical director Dr Pat Nash said yesterday.
Mr Halappanavar is to seek a meeting with Dr Reilly, said his solicitor, Gerard O'Donnell.
Mr O’Donnell said Mr Halappanavar was pleased that the process of finding out what had happened to his wife had “come this far”, but was still seeking accountability for her death.
He said his client was considering taking a negligence case or a constitutional action “seeking a declaration that Savita was deprived of her statutory right to have her life protected”.
A spokesman for the HSE said no proceedings had been initiated so far in relation to liability for her death, but it would consider its position, along with the State Claims Agency, if the situation changed.
