Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar executive summary and recommendations

摘要

The Authority identified, through a review of Savita Halappanavar’s healthcareudrecord, a number of missed opportunities which, had they been identifiedudand acted upon, may have potentially changed the outcome of her care. Forudexample, following the rupture of her membranes, four-hourly observationsudincluding temperature, heart rate, respiration and blood pressure did not appearudto have been carried out at the required intervals. At the various stages whenudthese observations were carried out, the consultant obstetrician, non-consultantudhospital doctors (NCHDs) and midwives/nurses caring for Savita Halappanavaruddid not appear to act in a timely way in response to the indications of her clinicaluddeterioration.udIn summary, of the care provided there was a:udn general lack of provision of basic, fundamental care, for example, notudfollowing up on blood tests as identified in the case of Savita Halappanavarudn failure to recognise that Savita Halappanavar was at risk of clinicaluddeteriorationudn failure to act or escalate concerns to an appropriately qualified clinician whenudSavita Halappanavar was showing the signs of clinical deterioration.udThe consultant, non-consultant hospital doctors (NCHDs) and midwifery/nursingudstaff were responsible and accountable for ensuring that Savita Halappanavarudreceived the right care at the right time. However, this did not happen.The most senior clinical decision maker involved in the provision of care to SavitaudHalappanavar at any given time should have been suitably clinically experiencedudand competent to interpret clinical findings and act accordingly. Ultimate clinicaludaccountability rested with the consultant obstetrician who was leading SavitaudHalappanavar’s care.udIn addition, the clinical governance arrangements within the Hospital failed toudrecognise that vital Hospital policies were not in use nor were arrangements inudplace to ensure the provision of basic patient care on St Monica’s Ward. Theseudincluded guidelines relating to the observation of obstetric patients through theuduse of a maternal early warning score chart and the management of sepsis andudpre-term pre-labour rupture of membranes. Furthermore, the healthcare medicaludrecord documentation of Savita Halappanavar’s care lacked detail in relation toudher clinical status and the potential risk of clinical deterioration at identified timesudthroughout her care pathway.