HSE publishes Report of the Investigation into the death of Ms. Savita Halappanavar

Thursday, 13th June 2013

The HSE today, Thursday 13th June 2013, published the report of the investigation into the death of Ms. Savita Halappanavar.  The HSE and University Hospital Galway apologises unreservedly to Mr. Halappanavar for the tragic and untimely death of his wife at University Hospital Galway on 28th October 2012.

This report was commissioned by the HSE to establish the facts and contributory factors leading up to the tragic death of Ms. Halappanavar and to provide recommendations.

The Investigation Team was chaired by independent expert, Professor Sir Sabaratnam Arulkumaran, Professor and Head of Obstetrics and Gynaecology and Deputy Head of Clinical Sciences at St George’s University of London and President of the International Federation of Obstetrics & Gynaecology. The investigation team also included a number of experts, both national and international, in the relevant disciplines (see note to editors for details).

The investigation to identify key causal factors involved a systems analysis of relevant records, interviews with 19 members of staff involved in Ms. Halappanavar’s care and the review of local, national and international guidelines. Mr. Halappanavar inputted to the investigation process through his representatives.

Overall the Investigation team found three key causal factors.

1.   Inadequate assessment and monitoring of Ms. Halappanavar that would have enabled the clinical team in UHG to recognise and respond to the signs that her condition was deteriorating. Ms. Halappanavar’s deteriorating condition was due to infection associated with a failure to devise and follow a plan of care for her that was satisfactorily cognisant of the facts that:

  • the most likely cause of her inevitable miscarriage was infection and
  • the risk of infection and sepsis increased with time following admission and especially following the spontaneous rupture of her membranes.

2.   Failure to offer all management options to Ms. Halappanavar who was experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to her was increasing with time from the time that her membranes had ruptured. 

3.   UHG’s non-adherence to clinical guidelines relating to the prompt and effective management of sepsis, severe sepsis and septic shock from when it was first diagnosed.

The investigation team has made a number of recommendations to address the key contributory factors that have been identified as contributing to this incident.

In response to the interim recommendations University Hospital Galway has already undertaken significant measures, including:

  • The implementation of early warning scoring systems;
  • The education of all staff in the recognition, monitoring and management of sepsis and septic shock; and
  • The introduction of a new multi-disciplinary team-based training programme in the management of obstetric emergencies, including sepsis.

UniversityHospital Galway has also improved communications processes and is implementing new procedures for doctors’ handovers.

Both University Hospital Galway and the HSE will work to fully implement all of the recommendations arising from the report in all hospitals.

Recommendation 1

Prompt introduction – followed by audit of compliance with - an appropriate Maternity Early Warning Scoring Systems Chart for patients receiving care for pregnancy complications on gynaecology wards. The Maternity Early Warning Scoring System Chart should define a coupled process of monitoring with activation of an escalating nursing, medical and multidisciplinary response.

Work on the Irish Maternal Early Warning Score (I-MEWS) commenced in 2012 and has been in place in all maternity units since April of this year. The Maternity Early Warning Scoring Systems (I-MEWS) allows a patient to be monitored using a standard guideline, coupled with a standardised escalating nursing, medical and multi-disciplinary response to be activated once complications are evident in a patient. A multi-disciplinary education and training programme in IMEWS has been rolled out across all 19 maternity hospital sites and a clinical guideline has been developed. Over 6,000 staff have been trained on the COMPASS programme for the early detection of deterioration in the patient’s condition. Training is compulsory in the National Early Warning score (NEWS) in intern training and is also part of undergraduate medical training.

Recommendation 2

Mandatory induction and education of all clinical staff working in obstetrics and gynaecology on the early recognition, monitoring and management of infection, sepsis, severe sepsis, and septic shock in accordance with appropriate clinical guidelines.

A multi-disciplinary team will be appointed to develop a national education and training programme for the management of obstetric emergencies; including the management of infection in pregnancy. This team will develop supporting resources for the introduction of guidelines on infection in pregnancy and provide training for staff on the guidelines.

Recommendation 2 also involves improved counselling services for women, husbands / partners following miscarriage and other serious incidents during pregnancy to ensure a standardised approach to counselling following a miscarriage.  This requirement will be communicated to all 19 maternity units.

Recommendation 3

The HSE should develop, disseminate and implement national guidelines on infection and pregnancy. The HSE should also develop multidisciplinary educational programmes to improve the quality of care in pregnancies complicated by infection. Specifically, there is a need for the development, implementation and audit of compliance with guidelines on the management of infection in pregnancy, suspected sepsis and sepsis in cases of inevitable miscarriage of an early second trimester pregnancy including where there is prolonged rupture of membranes and where the risk to the mother increases with time from the time that membranes were ruptured.

In addition to the guidelines and training already referenced above; a National Medication Programme for Obstetrics and Gynaecology will be developed and implemented through collaboration with the HSE Clinical Programmes for Obstetrics and Gynaecology, the National Medicines Programme and other relevant Clinical Programmes.  A clinical care pathway for the care of critically ill pregnant women is also currently being developed. This will deal specifically with the management of Obstetric emergencies including early recognition, monitoring and management of sepsis, severe sepsis and septic shock.

Recommendation 4a

Develop, implement and audit compliance with guidelines on the management of early second trimester inevitable miscarriage that are cognisant of the possible rapid deterioration of the patient from sepsis to severe sepsis to septic shock which could be within a few hours.

National guidelines have been developed on pre-term, pre-labour rupture of the membranes and these have been disseminated to all maternity hospitals. Work to complete the national care pathway on the care of critically ill pregnant woman is currently being finalised and will be disseminated to all maternity sites following consultation process.

The HSE will develop a national guideline setting out the correct procedures for the follow up of patient tests in hospitals.

Recommendation 4b

There is immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgement can be exercised in the best medical welfare interests of patients.

The implementation of this recommendation is beyond the role of the HSE.

Recommendation 5

The HSE should implement and audit compliance with improved communication practices between all disciplines and grades of staff, and implement improvements in the handover for acutely ill patients including between staff shifts.

The HSE has established a working group to improve communications between all staff and disciplines in the management and handover of patient care. This will review and recommend the most appropriate tools to support clear and focused communication of information; particularly relating to the deteriorating patient.

Recommendation 6

Development, implementation and audit of compliance of guidelines in line with the Royal College of Obstetricians and Gynaecologists Guidelines on the “Responsibility of the consultant on call” (RCOG Good Practice No. 8 - March 2009).

This will be considered by the group established to improve communications between hospital staff, as referenced in Recommendation 5.

- ENDS -

NOTE TO EDITORS:-

The Investigation team was chaired by independent expert, Professor Sir Sabaratnam Arulkumaran, Professor and Head of Obstetrics and Gynaecology and Deputy Head of Clinical Sciences at St George’s University of London and President of the International Federation of Obstetrics & Gynaecology.

Other members of the Investigation team include;

→ Ms. Cathriona Molloy, Service User Advocate, Patient Focus.

→ Dr. Brian Marsh, Consultant in Intensive Care Medicine, Mater Misericordiae Hospital, Dublin.

→ Ms. Geraldine Keohane, Director of Midwifery, Cork University Hospital.

→ Professor James Walker, Consultant Obstetrician and Gynaecologist, University of Leeds.

→ Prof. Mary Horgan, Consultant in Infectious Diseases, Cork University Hospital and Professor in the School of Medicine, University College Cork.

→ Ms Cora McCaughan, National Incident Management Team, HSE Quality and Patient Safety Directorate (Deputy Chairperson).

Last updated on: 13 / 06 / 2013