Intended for healthcare professionals


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

BMJ 2013; 346 doi: (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 …

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