The treatment received by Savita Halappanavar at Galway University Hospital in the days before her death bears a “disturbing resemblance” to the case of another pregnant woman who died six years ago, according to the report of the State’s health watchdog into her death.
The Health Information and Quality Authority report frequently draws comparisons between the case of Ms Halappanavar and that of Tania McCabe, who died at Our Lady of Lourdes Hospital, Drogheda, in 2007.
It is highly critical of the HSE’s failure to implement recommendations from the HSE report into the death of Ms McCabe on a national level, recommendations the health watchdog says had “particular relevance” to the case of Ms Halappanavar.
Ms McCabe was 34 years old and six months pregnant with twins when she presented at the Drogheda hospital on March 6th, 2007. She believed her waters were breaking.
Her consultant, however, believed she had “an episode of urinary incontinence rather than a rupture of membranes”, the HSE inquiry found.
Discharged
She was kept in overnight and the following morning a midwife noted she believed the woman's waters had broken. This information did not find its way to the consultant, who decided to discharge her.
When she returned to the hospital more than 30 hours later to give birth, sepsis had set in, which was a significant factor in her death, along “with haemorrhage as a complicating factor”. One of her twins also died.
As in the case of Ms Halappanavar, the HSE inquiry team found it was a “systems failure” that led to her death.
The report notes that only five of the country’s 19 maternity units were able to provide a detailed status update on the implementation of recommendations from the Tania McCabe report.
These were the Midlands Regional Hospital Mullingar, the Coombe in Dublin, the Rotunda in Dublin, Our Lady of Lourdes Hospital, Drogheda, and the Mid-Western Regional Maternity Hospital in Limerick.
Six of the 19 maternity units reported their status against a different investigation, had no comment, or reported that evidence for implementation was not in existence. “This is unsatisfactory and concerning,” says the report.
It also says the lack of a “nationally co-ordinated approach” to the implementation of the recommendations and the “ambiguity” regarding who has overall ownership of and responsibility for implementing the National Clinical Care Programmes raises “a fun damental and worrying deficit” in the State’s health system.
