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HSE Announces Details of the Investigation into the death of Ms Savita Halappanavar


19th November 2012

Internationally Renowned Expert in Obstetrics and Gynaecology to Chair the Investigation Team

– Investigation will identify any shortcomings that may be identified in the clinical care provided to Ms Halappanavar -

The HSE has today (Monday, 19th November 2012) announced details of the investigation into the death of Ms Savita Halappanavar.

Sir Sabaratnam Arulkumaran, an independent expert in obstetrics and gynaecology, will Chair the Investigation Team into her death. Sir Arulkumaran is Professor and Head of Obstetrics and Gynaecology and Deputy Head of Clinical Sciences at St George’s University of London. He is also the President of the International Federation of Obstetrics & Gynaecology.

The Investigation Team comprises a number of experts in the relevant disciplines; including anaesthesia, midwifery, obstetrics and gynaecology, to review the full range of clinical care provided to Ms Halappanavar. The team also includes an independent patient representative.

The HSE’s National Incident Management Team (NIMT) will oversee and support the investigation into the circumstances of Ms Halappanavar’s tragic death.

The members of the Investigation Team are;

  • Professor Sir Sabaratnam Arulkumaran, Head of Obstetrics and Gynaecology, St. George’s Hospital, University of London (Chairperson)
  • Ms Cora McCaughan, HSE National Incident Management Team
  • Ms Cathriona Molloy, Service User Advocate, Patient Focus 
  • Prof Morrison, Consultant Obstetrics and Gynaecology, Galway University Hospital          
  • Ms Geraldine Keohane, Director of Midwifery, Director of Cork University Hospital
  • Dr Catherine Fleming, Consultant Infectious Diseases, Galway University Hospital
  • Dr Brian Harte, Consultant Anaesthetics, Galway University Hospital

The Investigation Team met earlier today to review the Terms of Reference and agree their schedule for carrying out the investigation, which will be completed within an expeditious timeframe.

The process of clinical incident review seeks to ascertain the facts relating to the incident, identify any causal or contributory factors, draw conclusions, and make recommendations in relation to any steps that may need to be taken to prevent, insofar as it’s possible, and reduce the risk of a similar incident occurring again.  

Galway University Hospitalhas committed to cooperating fully with the team to ensure that this investigation can be completed as quickly as possible.

The Investigation Team has initiated contact with Mr Halappanavar’s legal representatives and will engage with him as part of the investigation process.

The final report of the Investigation Team will be provided to the HSE’s National Director of Quality and Patient Safety, Dr Philip Crowley.

Speaking at the press conference announcing today’s Investigation Team, Dr Crowley expressed condolences on behalf of the HSE to Ms Halappanavar’s family and friends for their tragic loss.

 “Our thoughts are with Ms Halappanavar’s family and friends at this difficult time. It is important that we ascertain the full facts of what occurred in this case and take all necessary steps that may be needed to be taken to prevent or minimise the risk of a similar incident occurring again. 

To do this we have an Investigation Team comprising of leading experts with vast experience across the range of clinical disciplines relevant to this tragic case. Under the Chairmanship of Sir Arulkumaran, we will have a thorough, independent, and expeditious review of the facts surrounding the tragic death of Ms Halappanavar.

We must now give the Investigation Team the time and support they require to conduct their inquiries before drawing any conclusions.

We must also remember that Ireland’s maternity services are of a very high standard and that as a country we have one of the lowest maternal death rates in the OECD.”

-  ENDS -

Investigation Team Details

Sir Sabaratnam Arulkumaran  

Professor & Head of Obstetrics and Gynaecology & Deputy Head of Clinical Sciences, St George’s University of London.

President of the International Federation of Obstetrics & Gynaecology.

Previous Posts

Honorary Secretary of Academy of Medical Royal Colleges, UK.

Board member of the Health Quality Improvement Partnership (HQIP), UK.

President ’07-’10; Vice President ’05-‘07 of the Royal College of Obstetricians & Gynaecologists (RCOG) of the UK.

Academic Record

Author of over 250 indexed publications, Editor/ author of 28 books and 190 book chapters; Editor in Chief of Best Practice and research in Clinical Obstetrics & Gynaecology.

Clinical Record

Over 40 years experience, of which 30 years in clinical and academic Obstetrics and Gynaecology.

Reorganised maternity services at Northwick Park hospital after it went to special measures on the recommendation of Health Care Commission.

Member of the National Clinical Advisory team that advises on reorganisation of services.

International Recognition

Honorary fellow of the American, Sri Lankan, South African, Pakistan, Indian, Australian & New Zealand & Japan Colleges of Obstetrics & Gynaecology and Hon. Member of the Canadian, Malaysian, German, Italian, Spanish and South African Societies and Hon. Doctorate in Science at the University of Athens.

Knight Bachelor in recognition of Services to Medicine by the Queen.

Cathriona Molloy, Service User Advocate, Patient Focus 

Founding member of Patient Focus, one of Ireland's leading national patient advocacy organisations. Ms Molloy has been working as a Service User Advocate for almost 14 years and is best known for her work in the Michael Neary case.

Patient Focus developed their service to provide a point of contact and other supports to patients who have been damaged by the healthcare system.

Ms Molloy was appointed to An Board Altranais in 2007 to represent the public interest and was a member of the HSE Miscarriage Misdiagnosis Incident Management Team.

Cora McCaughan, HSE National Incident Management Team

Ms McCaughan is currently Co-Chair of the HSE’s National Incident Management Team. Her work in this role has included the Miscarriage Misdiagnosis Review Report; The Report of the HSE investigation into the failure to transport a young girl to Kings College Hospital London for Liver Transplant.

Ms McCaughan is the Former Chairperson; Healthcare Risk Managers Forum (Ireland) and Chairperson of HSE Investigation Process Working Group; Irish Medical Council Standards in Practice Monitoring Committee.

She has aBSc Hons (Physiotherapy), Trinity College Dublin; MSc (Hons) Occupational Health and Ergonomics, NUI; Diploma Project Management and is currently undertaking PhD Studies in safety, risk and incident management at Trinity College Dublin.

Geraldine Keohane, Director of Midwifery and Nursing, Cork University Maternity Hospital

Ms Keohane is experienced in leading midwives and nurses in the provision of safe and high quality maternity, neonatal, and gynaecology services.

She has experience of working with multidisciplinary teams on the development, formation, implementation and review of midwifery and nursing protocols, policies and guidelines.

Ms Keohane is a Registered General Nurse and a Certified Midwife. She holds a Higher Diploma in Public Health Nursing, a BSc in Nursing Science and a Masters in Government and Public Policy.

Professor John J. Morrison MD FRCOG FRCPI BSc DCH

Professor Morrison has been a Consultant Obstetrician Gynaecologist at Galway University Hospitals since 1997. He is an accredited Royal College of Obstetrics and Gynaecology London Sub-Specialist in Feto-Maternal Medicine.

Prof Morrison is Chairman of the Academic Department of Obstetrics & Gynaecology at National University of Ireland Galway. He completed his Postgraduate Higher Training in Obstetrics & Gynaecology in University of Cambridge and University College London Hospitals.

Dr Catherine Fleming, Consultant in Infectious Diseases, Galway University Hospitals

Dr Fleming, MB BCH BAO, MPH, FRCPI is an honours graduate from University College Dublin (1990). She completed an Infectious Diseases Fellowship at Boston City Hospital and HIV Fellowship at Harvard University 1995-1999; MPH (Harvard University) 1999; Consultant in Infectious Diseases, Boston University 1999–2004; FRCPI 2005. 

Dr Brian Harte, Consultant in Anaesthesia and Intensive Care, Galway University Hospitals

Dr Harte, MB, FFARSCI, is a graduate of the National University of Ireland Galway (1991) and a Sub-specialist in Cardiot

Last updated on: 19 / 11 / 2012