Savita Halappanavar’s death ruled medical misadventure

 An inquest into the October 2012 death of Savita Halappanavar at Ireland’s University Hospital Galway found that staff failed to diagnose and promptly treat her condition. The jury ruled in a unanimous verdict that she died owing to “medical misadventure”.

Coroner Dr. Ciaran MacLoughlin found multiple “systems failures” at the hospital. These systems failures included: delays in following up on blood tests for results, lack of communication between staff and that the patient’s clinical signs were not monitored every four hours as they should have been. For example, the results of a blood test done when Ms. Halappanavar was first admitted to the hospital on Sunday were not followed up on until Wednesday. It showed an elevated white blood cell count which can be a sign of infection. Dr. MacLoughlin determined that staff had neither tested her blood sufficiently for signs of poisoning nor promptly examined the test results, which revealed signs of blood poisoning were present.

Signs of infection such as fever, chills and elevated pulse rate were missed as well. The coroner explained that the finding of systems failures did not mean that they necessarily contributed to her death.

The coroner also found hospital notes on Mrs. Halappanavar’s file were incomplete and unclear and had been amended after her death. Mrs. Halappanavar had advanced septicemia due to E.coli ESBL, which led to her death several days later from organ failure. Sepsis was not identified until it was too late.

Dr. MacLoughlin made recommendations on improving the hospital’s recording and sharing of patient information among staff and monitoring of patients’ risk of infection and blood poisoning. Moreover, he recommended that Ireland’s Medical Council publish guidelines defining the exact circumstances when a doctor can intervene to save a woman’s life. The Life Institute reports that the jury accepted the nine recommendations as of the Coroner but did not recommend any changes to Ireland’s abortion law.

Dr. Peter Boylan, who is on record as supporting the legalization of abortion in Ireland, was the key expert witness at the inquest.  He is clinical director of the National Maternity Hospital. The Life Institute questioned why Dr. Bolan was the only obstetrics expert called to give his opinion on Irish law at the inquest. He voiced his opinion that Mrs. Halappanavar would “on the balance of probabilities” have lived if an abortion had been performed one or two days before her unborn child died. In fact, the inquest did not find that Mrs. Halappanavar died because an abortion was not performed.

Eleven top consultants (obstetrician/gynecologists and other medical specialists) wrote to Irish newspapers concerning Dr. Boylan’s testimony. They stated:

“Sir,-The recent inquest on Savita Halappanavar has raised important issues about hospital infection in obstetrics. Much of the public attention appears to have been directed at the expert opinion of Dr Peter Boylan who suggested that Irish law prevented necessary treatment to save Ms Halappanavar’s life. We would suggest that this is a personal view, not an expert one.

Furthermore, it is impossible for Dr Boylan, or for any doctor, to predict with certainty the clinical course and outcome in the case of Savita Halappanavar where sepsis arose from the virulent and multi-drug resistant organism, E.coli ESBL. What we can say with certainty is where ruptured membranes are accompanied by any clinical or biochemical marker of infection, Irish obstetricians understand they can intervene with early delivery of the baby if necessary. Unfortunately, the inquest shows that in Galway University Hospital the diagnosis of chorioamnionitis was delayed and relevant information was not noted and acted upon.

The facts as produced at the inquest show this tragic case to be primarily about the mismanagement of sepsis, and Dr. Boylan’s opinion on the effect of Irish law did not appear to be shared by the coroner, or the jury, of the inquest.

Obstetric sepsis is unfortunately on the increase and is now the leading cause of maternal death reported in the UK Confidential Enquiry into Maternal Deaths. Additionally, there are many well-documented fatalities from sepsis in women following termination of pregnancy. To concentrate on our legal position regarding abortion in the light of such a case as that in Galway does not assist our services to pregnant women.

It is clear that maternal mortality in developing countries is rising, in the US, Canada, Britain, Denmark, Netherlands and other European countries. The last Confidential Enquiry in Britain (which now includes Ireland) recommended a “return to basics” and stated that many maternal deaths are related to failure to observe simple clinical signs such as fever, headache and changes in pulse rate and blood pressure. May of the failings highlighted in Galway have been described before in these and other reports.

…Ireland’s maternal health record is one of the best in the world in terms of our low rate of maternal death (including Galway hospital). The case in Galway was one of the worst cases of sepsis ever experienced in that hospital, and the diagnosis of ESBL septicaemia was almost unprecedented among Irish maternity units.

It is important that all obstetrical units in Ireland reflect on the findings of the events in Galway and learn how to improve care for pregnant women. To reduce it to a polemical argument about abortion may lead to more – not fewer- deaths in the future.”

 

Media articles are still circulating claiming that Mrs. Halappanavar died because she was denied an abortion. Unfortunately Savita’s tragic death following a miscarriage has been exploited for the purpose of pushing the legalization of abortion in Ireland.

“Top Irish doctors’ organization decisively rejects legal abortion,” Hilary White’s April 8th LifeSiteNews.com article, noted that Ireland’s constitution protects all human life from conception. But after years of lobbying by pro-abortion groups, the government introduced a bill in December 2012 to clarify when abortion is allowed under Irish law, claiming that women “denied abortion” would threaten to commit suicide.

During consultations, the government committee was repeatedly advised that the pro-abortion lobby was the source of this argument, and medical professionals stated that women are at a higher risk of serious mental illness, including depression and substance abuse, after having an abortion.

At the April 2013 Irish Medical Organisation (IMO) conference, pro-abortion campaign group Doctors for Choice brought forward motions to ask the government to legalize abortion in cases involving “real and substantial risk to the mother,” “non-viable foetal abnormalities,” or pregnancy resulting from rape or incest. The IMO voted to reject the motions.

Conference attendee and consultant psychiatrist Dr. Seán Ó Domhnaill of the Life Institute felt this vote dealt a blow to the government’s proposals. He commented that, “As doctors, we are trained to save lives, and most Irish doctors want to continue with the practice of protecting both mother and baby in pregnancy.”

Dr. Ó Domhnaill noted that allowing abortion in a “limited” way, such as that proposed by the government, could lead to abortion on demand, and “that’s not a model that any doctor should wish to follow.”

Dr. Berry Kiely of the Pro Life Campaign said the motions “would have allowed for abortion in wide-ranging circumstances as there was no duty of care towards the baby mentioned.” She observed that the government needed to consider the IMO vote as well as “the expert medical and psychiatric evidence presented at the recent Oireachtas [parliamentary] hearings showing that abortion is not necessary to save women’s lives.”

 

Life Institute also notes that “Women are not dying in this country because of our ban on abortion. That was confirmed most recently at the Oireachtas Committee hearings on abortion, where top obstetricians clearly stated that not one woman had died in Ireland because our pro-life laws prevented them from doing their job.”

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