PLC welcomes Savita inquest recommendations

By editor - 19 April, 2013

The inquest jury into the death Savita Halappanavar has found that she died due to medical misadventure and has made nine recommendations to ensure such a situation will not arise again. The Pro Life campaign has welcomed the inquest recommendations, including the call for Guidelines providing clarity for doctors in relation to medical interventions for women in pregnancy, which may result in the unintended loss of the baby.

During an eight day hearing, the jury heard of a series of medical systems failures including the lack of follow up on blood counts showing an elevated white cell count, the lack of monitoring of vital signs every four hours, failures in communications and a failure to administer a strong enough anti biotics.

Following the hearing, the eleven member jury delivered its verdict yesterday, tragically the fifth wedding anniversary of Praveen and Savita Halappanavar.

The jury made nine recommendations:

• Clearer medical guidelines on when a doctor can intervene to save the life of the mother
• Proper follow up on blood samples.
• Proper training and guidelines to be followed in the management of sepsis
• Proper and effective communication to occur between staff on-call and a team coming on duty and a dedicated handover time for such communications.
• Protocol for sepsis written by the department of microbiology for each hospital and each hospital directorate.
• A modified early warning score chart should be adopted by all hospitals in the state as soon as practicable.
• Early and effective communications with patients and/or their relatives to ensure that a treatment plan is readily explained and understood.
• Medical and nursing notes should be separate documents and kept separate.
• No additions should be made to the medical records of a deceased whose death is the subject of a coroner’s inquiry.

The jury stated the recommendations should be applied nationally.

Galway Coroner, Dr Ciaran MacLoughlin said the verdict did not mean that deficiencies or systems failures in University Hospital Galway contributed to Ms Halappanavar’s death; these were just findings in relation to the management of her care.

Addressing himself to Mr Halappanavar, he offered him his “sincerest and deepest” condolences on the death of his wife. “You showed tremendous loyalty in the love to her during her last week. The whole of Ireland has followed your story and I want, on their behalf, to offer our deepest sympathy.”

He went on:“You will also be watched over and protected by the shadow of Savita who was in our thoughts during this painful and difficult journey.” Mr Halappanavar sat with his legal team as the coroner, gardaí, the jury and legal teams for the hospital and its staff sympathised with him.

Reacting to the verdict, Dr Berry Kiely from the PLC welcomed its decision. She described as “little short of shameless” the manner in which those seeking the introduction of abortion legislation based on the X case ruling had exploited the tragic death of Savita Halappanavar all along, claiming that the failure to bring in such legislation was what led to Ms Halappanavar’s death.

“It is now clear from the facts presented at the inquest that a number of what the inquest terms ‘systems failures’ and communications shortcomings significantly delayed the moment at which the medical team recognised the seriousness of her condition and carried out the appropriate medical intervention.”

by Susan Gately