Laying Savita to rest

This week the official investigation into the death of Savita Halappanavar, the 31-year-old dentist who died of sepsis while 17 weeks pregnant at University Hospital Galway last year, was brought to a close with the publication of the Health Information and Quality Authority (HIQA)’s report into the care of clinically deteriorating patients in Irish hospitals.

irishtimesSavita’s request for an abortion during the course of her deterioration — and the prominence given to it in the initial reporting of the story by the Irish Times’ Kitty Holland, long before the clinical details of the case emerged — turned her death into a focal point for the campaign for abortion in Ireland, which succeeded in passing the Protection of Life During Pregnancy Act this summer. (See CV comment here and here).

Yet the HIQA investigation does not mention the request for termination in its timeline of missed opportunities, just as the nine recommendations made by the coroner’s report, which returned a verdict of medical misadventure, did not include a change in the law, instead focusing on the reform of national protocols for sepsis management.

savitaThough it investigated the quality and standard of care offered by Ireland’s Health Services Executive in general, the HIQA report focuses particularly on the treatment given to Savita at Galway in October last year, and makes 34 recommendations for the reform of Irish obstetric care based on the clinical failures that contributed to her death.

The HIQA identifies several “missed opportunities” for the identification and rapid treatment of Savita’s infection which could potentially have averted her death. At the top of the list is a “general lack of provision of basic, fundamental care”, such as the failure to follow up on crucial blood tests on the Sunday she was admitted, to make regular checks of temperature, heart rate, respiration and blood pressure following the rupture of her membranes the next day, and to prescribe prophylactic antibiotics when necessary.

When they did notice her deterioration, staff “did not appear to act in a timely way in response. A diagnosis of septic shock was not made until Wednesday afternoon and Savita continued to deteriorate until suffering cardiac arrest the following Sunday, passing away soon after.

The HIQA is clear: the mismanagement of Savita’s case is a symptom of Galway’s substandard provisions for the treatment of pregnant women. Though the hospital had in 2009 adopted a system to help identify at-risk maternity patients, this was not in use at the time of Savita’s admission. Their guidelines on suspected sepsis in obstretric care were not being properly adhered to, and hospital staff had received no specific training in their application. Galway had no guidelines at all for the management of sepsis in adult patients in general, and no consistent, hospital-wide definition of sepsis, severe sepsis and septic shock.

This is worrying, because sepsis is now the leading cause of direct maternal death in the UK. The annual number of reported cases has increased even as maternal mortality in general has declined. Blood tests found Savita was carrying ESBL-producing E.Coli, a bacterial strain that is particularly antibiotic-resistant and thus increasingly difficult to treat. Acknowledging the growing risks of antibiotic-resistant infection, the HIQA recommends round-the-clock access to microbiology laboratory services to rapidly identify pathogens and provide expert advice as needed, adding that it is “imperative that the risk associated with antimicrobial resistance is given a high priority at national and local levels.”

The issue of abortion, it turns out, was irrelevant to the Savita tragedy. Terminations of pregnancy where the mother’s life is at risk are in any case already permitted in Irish obstetric practice. The hospital has since apologised to Savita’s husband Praveen, and has promised to tighten up in a number of areas — without once mentioning the red herring of termination. Yet at the time, the outrage from pro-abortion groups — who chose to believe she had died as result of being denied an abortion — was intense. savita_halappanavar_ireland

The provisions in the new Protection of Life During Pregnancy Act for the direct and intentional taking of unborn life do nothing to improve best practice in these situations, and in fact hinder hospitals who already perform life-saving terminations.

For example, Dublin’s Mater Misericordiae, a Catholic hospital which performs five or six medically necessary terminations annually, has been thrown into uncertainty by the new law. Since the passing of the Act, one board member, Fr Kevin Doran, has resigned, while another says the hospital will not be performing abortions yet will be complying with the law.

Now that the facts are fully in the public domain, the significance of Savita’s untimely death has become clear: it is not about Ireland’s abortion laws, but about its maternal care. The case shows the growing risks of antibiotic-resistant sepsis and the shortcomings in obstetric care provision both at University Hospital Galway and across Ireland.

never againThe misreporting of this tragedy that began with the Irish Times and was taken up gleefully by the Guardian, which portrayed Savita as the victim of obscurantism and Catholic dogma, was a missed opportunity to bring major problems in maternal healthcare to public attention. The relentless focus on “abortion rights” by pro-choice activists is a distraction from the duty of care owed to women.

The true scandal of the Savita case is that Irish hospitals have been unable fully to vindicate women’s right to good quality healthcare, and an obsession with Irish abortion laws at the expense of this worrying reality helps neither women nor their unborn children.

Yet if the real lessons are learned, her death may yet save others’ lives.

[Megan Hodder]

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