Review finds 'number of missed opportunities to intervene' in Savita's care
on 09/10/2013 15:25:55
Medics treating Indian dentist Savita Halappanavar, who died after being refused a termination as she miscarried, failed to give her the most basic care, a damning review of her case has found.
Watchdog the Health Information and Quality Authority (Hiqa) said that doctors failed to recognise that she was suffering from an infection and failed to act on signs that she was deteriorating.
Director of regulation Phelim Quinn said there were a series of missed opportunities in Mrs Halappanavar's care in University Hospital Galway.
"The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar," he said.
"Effective care and treatment depends on the regular monitoring and recording of a patient's clinical observations and recognising their significance, acting appropriately on the findings, escalating concerns and the seamless clinical handover of information relating to each patient within and between clinicians and clinical teams."
Key findings of the Hiqa report included:
:: General lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in Mrs Halappanavar's case.
:: Failure to recognise that Mrs Halappanavar was at risk of clinical deterioration.
:: Failure to act or escalate concerns to an appropriately qualified clinician when Mrs Halappanavar was showing signs of clinical deterioration.
It is the third inquiry into Mrs Halappanavar's death from sepsis.
Investigations were also carried out by a coroner and the HSE.
Last April, the coroner found Mrs Halappanavar died because of medical misadventure while the HSE inquiry highlighted a number of failures by medics looking after her.
The Hiqa report examines the safety, quality and standards of HSE care for critically ill patients, including pregnant women, whose condition is getting worse.
Praveen Halappanavar, Savita's widower, is taking legal action against University Hospital Galway over alleged breaches of medical practice.
Mrs Halappanavar died in the Galway hospital on October 28 last year. She was 17 weeks pregnant when she was admitted a week earlier, having a miscarriage. She also suffered septicaemia.
The Hiqa inquiry has found that ultimate clinical accountability rested with her consultant obstretrician, Dr Katherine Astbury.
It stated that Dr Astbury was the most senior clinical decision-maker treating Mrs Halappanavar and 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," Hiqa stated.