Medics missed an early opportunity to terminate the pregnancy of a woman who later died from septic shock when she suffered a miscarriage in an Irish hospital, a scathing report has found.
The chairman of the clinical inquiry into the death of 31-year-old Savita Halappanavar revealed that he would have ended her pregnancy when she showed initial signs of the fatal infection.
But the renowned UK professor, Sir Sabaratnam Arulkumaran who headed the review on behalf of Ireland's Health Service Executive, refused to state when he would have acted or if it would have saved the dentist's life.
"It is very difficult. It's overall clinical judgment. I wasn't there to see how Savita was," he said.
The professor said that had Mrs Halappanavar had four-hourly pulse rate and temperature checks which recorded a rise, more tests could have been ordered and possibilities discussed. "Unfortunately none of this was done so I can't really say when would have been the ideal time," he said.
The review team highlighted a litany of failings that made a significant contribution to the Indian woman's death, including the interpretation of Ireland's strict abortions laws that only allows termination when there is a real and substantial risk to a woman's life; that staff did not adequately assess and monitor Savita as an infection took over her body; and that she was not offered all management options including termination.
They also found clinical guidelines relating to the prompt and effective management of sepsis at Galway University Hospital were also not followed, which includes removing the source of an infection.
Mrs Halappanavar's waters broke in the early hours of Monday morning and her condition deteriorated in the early hours of Wednesday morning. Her widower Praveen, who is out of the country, has maintained that she repeatedly requested a termination but was refused because a foetal heartbeat was present.
Professor Arulkumaran said the consultant's plan to "await events" is appropriate when there is no risk to the mother or foetus, but stressed that monitoring, evaluation and clinical investigations would likely have led to reconsidering the need to expedite delivery. By the Wednesday, a diagnosis of sepsis secondary to chorioamnionitis, an infection of the foetal membranes, was made which again would have merited expediting delivery to reduce the risk of infection to the mother, the review team said.
"The gravity of the situation was increasing but appears not to have been recognised and acted upon," the report found. "Awaiting the blood results and not fully appreciating the deteriorating and complex clinical situation missed an opportunity for early and appropriate intervention with the help of multidisciplinary input."