Verdict of medical misadventure in Savita Halappanavar inquestFriday 19 April 2013 22.12
The jury in the Savita Halappanavar inquest has returned a unanimous verdict of medical misadventure and has endorsed the coroner's nine recommendations.
Mrs Halappanavar was 17 weeks pregnant when she died last October at Galway University Hospital following a miscarriage.
The first of the recommendations is that the Medical Council should lay out exactly when doctors can intervene to save the life of a mother.
Coroner Dr Ciaran MacLoughlin had said this would provide clarity for patients and doctors.
The jury also endorsed recommendations that blood samples are always followed up to ensure errors do not occur; that proper sepsis management training and guidelines are available for hospital staff; and that there is effective communication between staff on call and those coming on duty in hospitals.
Dr MacLoughlin had recommended that a dedicated time should be set aside at the end of each shift for this to happen.
He had also recommended that each hospital in the State has a protocol for sepsis management; that modified early warning score charts are introduced in all hospitals as soon as possible; and that there is effective communication between patients and relatives to ensure they are fully aware of treatment plans.
The final two recommendations are that medical and nursing notes are kept separately and that no additions are made to notes, where the death of a person will be subject to an inquest.
The 11-member jury deliberated for two hours and 40 minutes.
Dr MacLoughlin offered his sincere and deepest sympathies to Praveen Halappanavar.
He said he had showed tremendous loyalty and love to his wife during her final days.
Addressing Mr Halappanavar, Dr MacLoughlin said "all of Ireland had followed the story" and he offered his sympathies on behalf of the country.
The coroner also clarified that the verdict of misadventure does not mean deficiencies or systems failures contributed to the death of Mrs Halappanavar.
Mr Halappanavar rose briefly from his seat to thank the coroner.
Questions left unanswered, says Praveen Halappanavar
Speaking after the verdict, Praveen Halappanavar said there were still some questions that he wanted answered and that he still had no clarity as to why his wife had died.
He told reporters he would look at taking further action to pursue the truth of what had happened, saying he owed it to his wife and her family to do that.
Mr Halappanavar said Savita's family wanted somebody to be held accountable for what occurred.
He described the treatment she received in the days after she was admitted to hospital as "horrendous" and said somebody had to take ownership for that.
Speaking outside the Galway County Council buildings, he said his wife had not benefited by going to the hospital until after 24 October, when she was moved to intensive care.
He said he felt doctors could have intervened as soon as they knew the pregnancy was not viable.
Mr Halappanavar said he would now "sit back and consider the next step".
He thanked gardaí, the coroner and the jury as well as his friends for the support they had given him.
Earlier, he said today was a poignant one as it was his wedding anniversary.
Mr Halappanavar said it had been a difficult time for him during the inquest.
But he said he was hopeful of "some bright days ahead" and that something good would come from the process.
Lapses in standards acknowledged
The Chief Operating Officer at the Galway Roscommon Hospital Group has acknowledged that there were lapses in the standards of care provided to Mrs Halappanavar.
Speaking after inquest, Tony Canavan said the deficiencies identified during the inquest would be rectified by the hospital and that all recommendations made by the coroner would be taken on board.
Mr Canavan said some of the recommendations had already been acted on.
In addition he said that the hospital would promptly implement all recommendations made by the HSE and HIQA reports into the death of Mrs Halappanavar.
Mr Halappanavar's solicitor Gerard O'Donnell said the effect of all the shortcomings identified during the inquest had a significant impact on Mrs Halappanavar.
He said the evidence demonstrated a serious and shocking mismanagement of the patient at Galway University Hospital.
Mr O'Donnell said she had been denied and deprived of proper medical treatment when it was urgently needed.
He said no intervention was made until such time as the foetal heartbeat stopped and when intervention came, it was from staff at the hospital's intensive care unit.
The solicitor said it was extremely worrying to think that Irish women suffering from sepsis would have to wait until they were gravely ill before an intervention could occur.
He urged the Government to look at the issue and to introduce legislation, if needed, urgently.
Mr O'Donnell said Mrs Halappanavar was denied of her constitutional right to life and was the victim of a significant breach of human rights.
Minister for Health James Reilly said that "as the verdict had just been issued and because he must consider it in detail, to garner the lessons to be learned from it, it would not be appropriate for him to take questions on it right now."
He said: “It's most important to go back to the central reality here, that is that a young woman has died and her baby died with her, and a young man has lost his wife and his daughter.
“What followed this tragedy has been desperately hard on Mr Praveen Halappanaver and his family and the family of the late Savita Halappanaver and I don't want to add to it in any way by making any kind of general comment at this time.
“The fact that Dr Ciaran McLoughlin has conducted this inquest with authority and thoroughness must be registered as must my intention to ensure that everything we learn from this inquest, from the clinical review and from the HIQA examination of this tragedy will feed into guidelines, protocols and checklists in maternity and other hospitals to keep patients safe”, he said.
Follow @FergalBowers for updates