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Coroner identifies two failings in care of woman who died after being refused an abortion

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2441 (Published 16 April 2013) Cite this as: BMJ 2013;346:f2441
  1. Muiris Houston
  1. 1Galway

At the end of the first week of the inquest into the death of Savita Halappanavar, the dentist who died from septicaemia at University Hospital Galway when 17 weeks pregnant, the coroner, Ciarán MacLoughlin, has identified two system failures during her care last October.

The first involved the failure of medical staff to follow up the results of a full blood count that was taken on her admission on 21 October. MacLoughlin said that each clinical team in the obstetrics department had a responsibility to check blood results of patients under its care. The inquest had earlier heard from the admitting senior house officer that she did not think that it was up to her to follow up the test result.

It later emerged that the full blood count had shown a significantly raised white cell count, but this was not noticed until two days after the patient’s admission.

The second system failure, the coroner said, was the failure of nursing staff to fully carry out four hourly measurements of Halappanavar’s vital signs after the fetal membranes had ruptured, as laid out in hospital guidelines.

The inquest heard evidence that the observation of her vital signs on Tuesday night and Wednesday morning was incomplete. The consultant obstetrician, Katherine Astbury, said that she looked for a trend in these readings and that the omission of one set of readings in a 24 hour period would not hamper this ability. However, the coroner stated that there had been a failure in the system of nurses’ recording of Halappanavar’s vital signs in the obstetrics unit at a crucial time in her care.

Later, an expert witness, Susan Knowles, consultant microbiologist at the National Maternity Hospital in Dublin, told the inquest that Halappanavar should have received more effective antibiotics earlier in her care. She said that the Galway hospital’s own guidelines on administering antibiotics in cases of sepsis were not followed for a number of hours on Wednesday 24 October last year. If the flow chart in the guidelines had been followed, Halappanavar would have had effective treatment from 7 am on the day, rather than 1 pm.

“I believe that antibiotics with a broader range of cover for gram negative bacteria including E coli should have been administered at that time for suspected sepsis and chorioamnionitis,” Knowles told the inquest. However, she acknowledged that the choice of co-amoxiclav in this case was in line with recommendations from the latest triennial report from the Confidential Enquiries into Maternal Deaths in the United Kingdom, Saving Mothers’ Lives 2006-2008, although she said that many centres in Ireland would use an additional antibiotic in view of the increasing resistance of many strains of E coli to co-amoxiclav.

In addition to medical evidence, witnesses gave testimony about the legal and religious aspects of the case. The clinical midwife manager, Anna Maria Burke, told the inquest that it was she who had spoken to Halappanavar about Ireland being “a Catholic country.” A reference to this being the reason why the patient had not been offered a termination of pregnancy caused an international outcry when the story first broke.1

Burke said that she now regretted the remark but explained that it wasn’t meant to be hurtful. It was in the context of a chat and had nothing to do with the provision of care, she told the inquest. “It was not said in the context to offend her. I’m sorry how it came across. It does sound very bad now, but at the time I didn’t mean it that way,” she said. Praveen Halappanavar, the deceased’s husband, welcomed and accepted her apology.

Earlier Astbury had denied that she referred to religion in her conversations with the Halappanavars. She said it was her understanding that Irish law did “not permit termination even if there is no prospect of viability [for the fetus]” and that abortion was illegal unless there was “a real and substantive risk to the life of the mother.” Astbury emphasised that in addition to the relevant Medical Council guideline on the matter, she also required there to be a balance of probabilities (≥51%) of a risk to the life of a mother.

The decision to terminate Halappanavar’s pregnancy was taken at 1.20 pm on Wednesday 24 October because her condition had deteriorated to such an extent that Astbury judged that her life was now at risk. However, before the termination was initiated, Halappanavar spontaneously delivered a female fetus.

Commenting on the evidence to date, the minister for justice, Alan Shatter, said that there had been “legal confusion” in the case.

“In the tragic case presently being dealt with in the Coroner’s Court in Galway, we have seen the type of difficulties that can arise when there is legal confusion,” Shatter said when asked about abortion legislation currently being prepared by the Irish government.2 “I think it’s been a difficult and confused area for too long.”

The inquest is due to resume on Wednesday 17 April, when further expert evidence is expected to be heard.

Notes

Cite this as: BMJ 2013;346:f2441

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