Early termination, if legally permissible, could have saved Halappanavar - expertWednesday 17 April 2013 22.59
An expert witness at the Savita Halappanavar inquest has said that a termination of pregnancy was warranted by law on the morning of Wednesday 24 October.
The National Maternity Hospital's clinical director, Dr Peter Boylan, has been giving evidence to the inquest, which is in its sixth day.
Dr Boylan said staff had to wait for the arrival of sepsis to intervene because of the legal position.
Mrs Halappanavar died on 28 October 2012 at Galway University Hospital.
He said it was his view that the 31-year-old would be alive today if a termination had been carried out earlier, but this was not a practical proposition because of the law.
In reviewing the treatment provided to Mrs Halappanavar, Dr Boylan told the jury the key question he looked at was whether at any point there was a real and substantial risk to the patient if her pregnancy was not terminated.
He said there was no such threat on 22 or 23 October - dates on which her husband Praveen said she requested a termination.
By 24 October, however, Dr Boylan said the rapid deterioration in Mrs Halappanavar's health meant that intervention was warranted and legally permissible.
He said that a number of indicators of severe sepsis were present at 6.30am that day.
The prospect of a termination was under consideration following ward rounds at 8.20am.
Dr Boylan said that even if the process had commenced by 9.30am, the eventual outcome would not have changed due to the rapid onset of sepsis.
In his conclusion, he said that there had been deficiencies in the care provided at Galway University Hospital.
None of these on their own resulted in Mrs Halappanavar's death, but cumulatively they resulted in delays to the treatment she received.
Dr Boylan said the real problem was the inability of medics to carry out a termination before there was a risk to Mrs Halappanavar's life or health, due to the legal situation.
He also said it would have been useful if the midwife who treated Mrs Halappanvar on the Wednesday morning had made a statement to the inquest.
Coroner Dr Ciaran McLoughlin explained to the jury that this staff member was not in a position to do so for reasons that had been certified, explained and accepted by the coroner.
When the inquest resumed after lunch, Dr Boylan was cross-examined by Eugene Gleeson SC for Mr Halappanavar.
He told Mr Gleeson that it is reasonable to say that Mrs Halappanavar merited clinical review at 4.15am on the morning of 24 October, when she complained about being cold and was shivery.
Her temperature was the only one of four vital signs taken at this time and she was not reviewed by a doctor until 6.30am.
Dr Boylan said treatment would have been accelerated had she been seen by a doctor then.
He said that things went seriously wrong for Mrs Halappanavar between 5.15am and 6.30am as sepsis took hold and infection spread.
Witness questioned about abortion guidelines
Questioning then focused on the Medical Council guidelines on abortion.
Dr Boylan has said that obstetricians work on the basis that abortion is illegal, except where there is a real and substantial risk to the life of the mother, as opposed to the health of the mother.
He said that to some extent obstetricians in Ireland are working in a vacuum, as there are no guidelines as to how that risk was judged.
Dr Boylan said many people could not understand the law, but medical staff had to work within the confines of the law as it stood.
He said Mrs Halappanavar had an aggressive infection, which resulted in severe and rapid onset of septic shock. He said that essentially in her case, the arrival of sepsis had to be awaited before a termination could be considered.
Dr Boylan said the time it takes for septic shock to take hold can vary, but the onset can be fast and "absolutely catastrophic".
Witness reviews attention given to Mrs Halappanavar
Dr Boylan also reviewed the attention given to Mrs Halappanavar in the early hours of Wednesday 24 October.
He agreed with Counsel for Galway University Hospital Declan Buckley, who put it to him that the rarity of the condition which affected Mrs Halappanavar had to be borne in mind, when retrospectively considering the staff response.
Mr Buckley referred to evidence given by nurse Miriam Dunleavy last week, who told the inquest she had never seen a patient get "so sick, so quick" in a period between 4.15 and 6.30 that morning.
Dr Boylan said he agreed that symptoms were found to be agreeable when nurse Dunleavy responded to a call from Mrs Halappanavar at 4.15 but he said her pulse should have been checked along with her temperature at that time.
He said that ideally this would have happened before paracetemol was given.
Dr Boylan said paracetamol can reduce temperature but also "confuse the clinical picture".
Midwife and doctor return to inquest
Differences still remain about a conversation between a doctor and a midwife about a deterioration in Mrs Halappanavar's condition on Tuesday 23 October.
When she was recalled to the inquest this morning, midwife Ann Maria Burke said she was "100% certain" that she told a doctor about Mrs Halappanavar having an elevated pulse rate in a phone call that evening.
This is disputed by Dr Ikechkwu Uzockwu.
Ms Burke has told the inquest that she called Dr Uzockwu at 7.35pm the evening in question to ask if Mrs Halappanavar could have a bath.
She said the doctor told her she could not and that she then made him aware of an elevated pulse reading of 110, which had been taken 20 minutes earlier.
When questioned by the coroner and barrister John O'Donnell this morning, Ms Burke was adamant that she had alerted the doctor.
When he entered the witness box, Dr Uzockwu said his recollection was of getting a call between 9pm and 11pm that evening, but said that no reference was made to an elevated pulse at that time.
He was not sure who had called him.
The doctor called to Mrs Halappanavar's room at 1am on the morning of 24 October, but did not review her as she was sleeping.
Dr Uzockwu said he was told by another midwife at that time that observations were stable and within normal range.
Mrs Halappanavar's medical records show that her vital signs were recorded at 9pm on 23 October, but that the four indicators were not all checked again until 6am the following morning.
Her temperature was taken at 4.15am and 5.15am.
The inquest heard evidence on post mortem examination results on Mrs Halappanavar and her baby.
Mr Halappanavar left the inquest room during that evidence to avoid distress.
The inquest has adjourned for the evening and will resume tomorrow morning when the final two witnesses will give evidence.
Dr McLoughlin has indicated that he will sum up and charge the jury on Friday.
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