The midwife manager on St Monica's Ward at University Hospital Galway has confirmed that it was she who told Savita Halappanavar that her pregnancy could not be terminated because Ireland was a "Catholic country" but added that was not meant in a hurtful context.
Ann Maria Burke took the witness stand at the inquest last evening and in a statement told the Coroner she was very upset about the matter and that she did not mean the remark about Ireland in a hurtful context.
She said that with hindsight she said it "sounded bad" and the remark was something she said that she regretted.
Ms Burke said she was giving Mrs Halappanavar information because Mrs Halappanavar was puzzled.
"She had mentioned the Hindu faith and that in India a termination would be possible," Ms Burke said, adding that the remark had "come out the wrong way and I'm sorry that I said it".
“I was trying to be as "broad and explanatory as I could". It was nothing to do with medical care at all,” she said.
Dr Ciaran McLoughlin said the remark had gone around the world and he stated public hospitals in Ireland did not follow religious dogma of any persuasion.
Meanwhile, a consultant obstetrician has denied ever referring to religion when the issue of a termination was discussed and said that she felt constrained by Irish law which prevented her from intervening while a foetal heart beat was still present.
Dr Katherine Astbury was giving evidence yesterday at the inquest which began at Galway courthouse last Monday and is expected to run into next week with more than 53 witness statements involved. Savita, a 31-year-old dentist from India, had been 17 weeks pregnant when she was admitted to UHG on Sunday, October 21. Despite requests for a termination being made Savita was diagnosed with sepsis on the morning of Wednesday, October 24, progressing to septic shock by lunchtime that same day. Her condition deteriorated rapidly and she was transferred to the high dependency unit before being placed in intensive care the following day. Savita then suffered multiple organ failure and passed away on Sunday, October 28.
During the course of the inquest it was maintained by Praveen Halapannavar and his legal team that at least three requests for a termination - to help what the couple had been told was an inevitable miscarriage - were made, but that these had been refused. When questioned by Eugene Gleeson SC, about the specific words used when one such request was made on Tuesday, October 23, during morning rounds Dr Astbury replied: “We were discussing when delivery was likely to take place, Savita said she was finding it hard and upsetting knowing that it was unlikely she was going to have a live baby and she didn’t want to sit and wait. I said that in this country it is not legal to terminate the pregnancy on the grounds of poor prognosis of the foetus”. She added that even if there was “no prospect” of viability the law did not allow her to intervene at that stage. Mr Gleeson then put it to the witness she had actually said, “Unfortunately I can’t, this is a Catholic country, we are bound by the law and cannot terminate because the feotus is still alive.”
“I made no reference to religion. I said I cannot terminate in Ireland because of the law,” Dr Astbury retorted, before agreeing that if such words had indeed been spoken then it would certainly have been insensitive. Earlier Dr Astbury told the inquest that when she first saw Savita, on Monday October 22, she could not, at that stage, exclude the possibility that the pregnancy had a slim chance of continuing and that there have been cases where ruptured membranes have reached viability.
“It [ruptured membrane] increases the chance of delivery, but it doesn’t rule out viability. There have been ruptures under 20 weeks that have between a 12 and 18 per cent chance of viability. My impression was that she [Savita] was going to deliver the foetus. That was the likelihood, not an absolute certainty,” said Dr Astbury.
Noting that in cases of a ruptured membrane intrauterine infection is probable, Mr Gleeson asked Dr Astbury if she had been “holding out” for the viability, however slim, of the foetus, while Savita was distressed and asking for a termination.
“She was emotionally distressed, she was not physically unwell [at this point]. The law states that in the absence of a risk to the mother there is no reason to terminate, it is not legal in the context she was requesting,” replied Dr Astbury.
Communication of vital information could have meant earlier intervention
The inquest heard that it was not until later Dr Astbury’s opinion about the substantial risk to Savita’s health changed prompting her to consult senior colleagues on the need to intervene. Referring to evidence given on Tuesday which revealed a breakdown in communication between a midwife and senior house officer on duty, Dr Ikechukwu Uzockwu on the evening of October 23 regarding Savita’s raised heart rate, Dr Astbury agreed that this should not have happened and that she should have been informed of the situation. Mr Gleeson reminded the inquest that Savita had not been checked again by a doctor until 6.30am Wednesday, October 24. He added that at 8.25am the diagnosis should have been made and the appropriate response taken. “It had been your intention at that point to induce? You would have expedited that by a number of hours if other information had been made known?” asked Mr Gleeson. Dr Astbury agreed with this, adding that in her opinion the viability of the foetus had been lost on the Wednesday morning and that the “ultimate treatment would be to deliver”.
Dr Astbury then told the inquest that she felt constrained by Irish law which prevented her from intervening while there was still a poor prospect of viability and the presence of a feotal heart beat. “My understanding is that there has to be a real and substantial risk to the life of the mother until you can intervene,” she said.
When asked questioned by her own legal representative, Eileen Barrington, Dr Astbury said that a discussion took place on the Monday, October 22, regarding the available management options - that if the foetal heart beat stopped then medication could be given to induce delivery but if not, then it would be a case of waiting and monitoring to ensure that the mother was well. Dr Astbury refuted evidence given earlier in the inquest that a formal request had been made by Savita and that she had gone to check with other colleagues about the possibility of a termination. Regarding Mr Halappanavar’s evidence that another discussion had taken place the following morning about a termination, Dr Astbury said that she had carried out her morning rounds at 8.20am and did not have a conversation with him on that day. She again denied making any reference to religion in any conversation with Savita or her husband.
Earlier yesterday, Dr Astbury admitted that had she been informed that a blood test taken when Savita was admitted returned an abnormal white cell count she would have asked for a re-check and intervened sooner. She added that vital sign readings are usually taken every four hours but that there could be longer periods between during the night.
Galway West Coroner Dr Ciaran MacLoughlin noted that this seemed to suggest that there was a system failure. He said: “There was a spontaneous rupture of the membrane, vitals were meant to be checked every four hours, and the white cell blood count was not communicated. Those are two system failures.” Dr Astbury agreed that this may be the case but added that the problem lay more with Irish law than hospital guidelines.
Giving evidence on day two of the inquest, specialist registrar Dr Andrew Gaolebale, who had admitted Savita to hospital on October 21, said that he had informed the couple that the foetus was not viable but strenuously denied advising them that the inevitable miscarriage would all be over within four to five hours and then they could go home. “No one could ever put a time on a process like that. I didn’t know how long it would take,” said Dr Gaolebale, who also confirmed that had he been informed the white cell blood count was abnormal he would have repeated the blood test.
Senior house officer, Dr Ikechukwu Uzockwu, gave evidence that he was contacted on October 23 between 9pm and 11pm and told that Savita was complaining of weakness, but that her vital signs at this point had been within normal range. However by 6.30am on October 24, Savita had developed a fever with a fast heart rate. Dr Uzockwu said that he attended immediately to find that Savita’s condition had deteriorated to such that she had to be put on oxygen and a number of tests were carried out including an ECG.
Mr Gleeson put it to Dr Uzockwu that a student midwife had taken Savita’s pulse on October 23, at 7.15pm, and found it to be raised to 114, but that a more senior midwife had ordered a recheck and the pulse was 110. Adding that this level was still very high, Mr Gleeson asked the witness if he should have been informed of this straight away. “I was told that the vital signs were stable, I wasn’t told about the elevated pulse,” said Dr Uzockwu, who agreed that when there is a woman with a ruptured membrane, and risk of infection, he would have been concerned with the elevated pulse rate and would have attended Savita immediately.
Midwife Miriam Dunleavy described how the rate of Savita’s deterioration had “frightened” her and a colleague. “I have never seen a woman with inevitable miscarriage get so sick so quickly on the ward,” said Ms Dunleavy, who confirmed that a doctor in charge should have been informed of the elevated heart rate.
The inquest continues today.