Failure to capitalise on ‘missed opportunities’ to intervene in the care of Savita Halappanavar which could have changed the outcome for her, could have prevented her death at University Hospital Galway almost 12 months ago, it was claimed last evening.
That stark finding was contained in the report issued last evening by the Health Information and Quality Authority (HIQA ) which had been tasked by the Health Service Executive to investigate the safety, quality, and standards of services provided at University Hospital Galway after the death of Mrs Halappanavar on October 28, last year.
The report, running to almost 260 pages, found that a failure to provide the most basic elements of care in her case was instrumental in the tragic outcome for the Galway city resident who died one week after she was admitted to the hospital when she was 17 weeks’ pregnant and miscarrying.
The report also revealed wide variations in clinical care in the 19 public maternity hospitals and units and has led to a series of 34 recommendations on improving the care of clinically deteriorating pregnant women throughout the country.
Fifteen of these recommendations were made to the Hospital group which runs University Hospital, Galway and relate to leadership, governance, staff training, communication, current practices and will make for disturbing reading for service users.
The report also stated there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally, as well as no centralised approach to reporting maternal morbidity and mortality.
As a result, it is impossible to properly assess the performance and quality of maternity services nationally, the report found.
In the case of Mrs Halappanavar, the report said there was a failure to recognise she was developing an infection and to act on her deteriorating condition.
It found that University Hospital Galway did not have effective arrangements to regularly record and monitor her condition and that the management of the delivery of maternity services was not consistent with best practices.
The report stated the findings in the Halappanavar case bear a disturbing resemblance to the findings in the HSE inquiry into the death of Tania McCabe and her son Zach, in 2007, at Our Lady of Lourdes Hospital in Drogheda.
It also called for a National Maternity Services Strategy to ensure women receive safe, high quality, and reliable care.
The inquest into the death of Mrs Halappanavar took place in April and found she had died due to medical misadventure.
A HSE clinical review report was published in June, which found inadequate assessment and monitoring and a failure to recognise the gravity of the situation and the increasing risk to her life.
Last month, it was announced that Mrs Halappanavar’s husband Praveen is to take a legal case against the HSE and Dr Katherine Astbury.