European & International News

Ireland: Inquest into Savita’s death finds medical misadventure

(Galway 19 April 2013) The coroners inquest into the death of Savita Halippanavar in Ireland in October last has today reached a verdict of ‘medical misadventure’. After a two and a half hour deliberation the foreman of the jury told Galway West coroner Dr. Ciaran MacLouglin it had reached the unanimous verdict of medical misadventure and strongly endorsed his nine recommendations "after much consideration". The seven day inquest has heard evidence from the medical team who provided care for Mrs. Halippanavar.

The death of Mrs. Halippanavar, a dentist from India, who entered hospital with a suspected miscarriage and who died in hospital a week later, has brought the debate about abortion back to the forefront of Irish and international political and societal debate. The cause of death was septic shock, E coli in her bloodstream and a miscarriage at 17 weeks.

Her husband Praveen’s claim that he was told that his wife, despite several requests, could not get an abortion, because "Ireland was a Catholic country", has been vindicated. Abortion in Ireland, since a 1992 Supreme Court Case, called the X Case, has been legal only when the life of the mother, as distinct from her health, is at risk from the continued pregnancy. When she first attended hospital with back pain and miscarrying, there was not a real and substantial risk to her life at that stage - but by the time that her life was in danger, it was too late to save her life.

The jury endorsed the nine recommendations suggested by Dr. Ciaran MacLouglin. Critically, the first recommendation calls for the Medical Council to lay out when and where doctors can intervene to save the life of a mother in similar circumstances.

The recommendations

  • 1 The Medical Council should lay out exactly when a doctor can intervene to save the life of the mother in similar circumstances, which would remove doubt and fear from the doctor and also reassure the public. An Bord Altranais (Nurses Board) should have similar directives for midwives so that the two professions always complement one another.
  • 2 Blood samples should be properly followed up and proper procedures put in place to ensure errors don’t occur. That would be a national recommendation.
  • 3 Protocols should be followed in the management of sepsis and there should be proper training and guidelines for all medical and nursing personnel. And that would be a national recommendation.
  • 4 Proper and effective communication to occur between staff on-call and a team coming on duty and a dedicated handover time to be set aside for such communications. That should be applied nationally.
  • 5 Protocol for sepsis written by the department of microbiology for each hospital and each hospital directorate. And that should be applied nationally.
  • 6 A modified early warning score chart should be adopted by all hospitals in the state as soon as practicable.
  • 7 There should be early and effective communications with patients and/or their relatives to ensure that a treatment plan is readily explained and understood. And this should be applied nationally.
  • 8 The medical notes and nursing notes should be separate documents and kept separate. And that should be applied nationally.
  • 9 No additions should be made to the medical records of a deceased whose death is the subject of a coroner’s inquiry. Additions may inhibit the inquiry and prohibit the making of recommendations which may prevent further fatalities. And that should be applied nationally.

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