The following is the Health Service Executive's draft terms of reference in the Savita Halappanavar inquiry.

These are the terms of reference for an incident that arose at the hospital on 28/10/2012. This investigation will be overseen by the National Incident Management Team (NIMT). The final report will be provided to the National Director of Quality and Patient Safety.


The purpose of this investigation is to:

- Establish the factual circumstances leading up to the incident

- Identify any key causal factors that may have occurred

- Identify the contributory factors that caused the key causal factors

- Recommend actions that will address the contributory factors so that the risk of future harm arising from these factors is eliminated or if this is impossible, is reduced as far as is reasonably practicable.

Scope of the Investigation/Review

The time frame of this investigation/review will be from patient’s admission to GUH on the 21/10/2012 to the patient’s death on the 28/10/2012.

The investigation members

Membership of the investigation team includes:

- Professor Sir Sabaratnam Arulkumaran, Head of Obstetrics and Gynaecology, St. George’s Hospital, University of London (Chairperson)

- Ms Cora McCaughan, National Incident Management Team (Deputy Chairperson)

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

- Professor James Walker, Professor and Honorary Consultant of Obstetrics and Gynaecology in St James’ University Hospital in Leeds, UK.

- Professor Mary Horgan, Consultant Physician in Cork University Hospital and Professor in the School of Medicine, University College Cork.

- Dr. Brian Marsh, Consultant in Intensive Care Medicine, Mater Misericordiae University Hospital and immediate past-Dean, Joint Faculty of Intensive Care Medicine of Ireland

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

Through the Chairperson, the investigation team will:

- Be afforded the assistance of all relevant staff and other relevant personnel.

- Have access to all relevant files and records (subject to any necessary consent/data protection requirements including court applications, where necessary).

Should immediate safety concerns arise, the Chair of the Investigation Team will convey the details of these safety concerns to the Commissioner as soon as possible.

Should the investigation team require further external independent input, the Chair of the Investigation team will discuss this with the commissioner; and will seek this input through the NIMT.

Investigation method

The investigation will follow the HSE Guidelines for Systems Analysis Investigation of Incidents and Complaints (QPSD November 2012) and will be cognisant of the rights of all involved to privacy and confidentiality; dignity and respect; due process; and natural and constitutional justice.

The investigation will commence with immediate effect and will be conducted in the shortest timeframe necessary to achieve the purpose of the investigation.

Following completion of the investigation, an anonymised draft report will be prepared by the investigation team outlining the chronology, findings and recommendations. All who participated in the investigation will have an opportunity to give input to the extracts from the report relevant to them to ensure that they are factually accurate and fair from their perspective.

The anonymised report will be shared with the next of kin and may be published and may be subject to a Freedom of Information request.

Recommendations and Implementation

The report, when finalised, will be presented to the commissioner of the investigation.

Implementation of locally applicable recommendations will be undertaken by local managers.

Local managers will communicate nationally applicable recommendations to the National Director(s) and the National Director(s) will oversee the implementation of the nationally applicable recommendations.

Communication Strategy for the Investigation

An individual will be appointed for the purpose of communicating information pertaining to the investigation to the family/staff member(s) affected by and/or involved in the incident.