A HSE report has found that the lack of legal clarity on terminations in Ireland was a contributory factor in the death of Savita Halappanavar.

The report was carried out by a panel of seven experts, led by Dr Sabaratnam Arulkumaran following the death of Savita Halappanavar in October last year.

The 31-year-old died from septecaemia following a miscarriage at University Hospital, Galway.

It has identified three key causal factors that led to her death:

• Inadequate assessment and monitoring which would have allowed clinical team to recognise and respond to signs that the patients condition was deteriorating.
• Failure to offer all management options - including termination - to the patient experiencing inevitable miscarriage - where the risk to the mother increased with time.
• Non adherence to clinical guidelines for managing sepsis.

And it goes on to make a number of recommendations: (see also below)

• Prompt introduction of an Early Warning Scoring Systems Chart for patients with pregnancy complications - and an audit of compliance with it.
• Mandatory education of all clinical staff in obstetrics and gynaecology on the early recognition of sepsis.
• HSE should develop national guidelines on infection and pregnancy - they should specifically include clarity about who is responsible for following up and acting on results of tests.
• Develop guidelines on managing second trimester inevitable miscarriage.
• Immediate and urgent requirement for a clear statement on the legal context in which clinical professional judgement can be exercised in the best medical interests of the patients.
• Improve communication between all staff.
• Develop guidelines on when to call in senior medical staff - including consultants.

The report highlights an "over-emphasis on the need not to intervene until the fetal heartbeat stopped altogether" as well as an "under-emphasis on the need to focus attention on the mother". And it warns that similar incidents could happen again in the absence of clarity as to the application of the law when it comes to termination of pregnancy.

Speaking at the publication of the report at HSE headquarters in Dublin, Dr Sabaratnam Arulkumaran said were Savita his patient, he "would have offered a termination" if there were no legal obstacles. He said the the legal situation in Ireland was a "significant factor" in her death.

He also hopes their recommendations will be implemented at all Irish maternity hospitals.

Dr. Arulkumaran says the medical community - as well the law - needs to change.

The Health Service Executive and University Hospital Galway have apologised unreservedly to Savita Halappanavar's husband Praveen and her family. The HSE and University Hospital Galway say they will fully implement all the recommendations in the report.

Dr. Patrick Nash is the Clinical Director at UHG.

Recommendation 1
Prompt introduction – followed by audit of compliance with - an appropriate Maternity Early Warning Scoring Systems Chart for patients receiving care for pregnancy complications on gynaecology wards. The Maternity Early Warning Scoring System Chart should define a coupled process of monitoring with activation of an escalating nursing, medical and multidisciplinary response.

Work on the Irish Maternal Early Warning Score (I-MEWS) commenced in 2012 and has been in place in all maternity units since April of this year. The Maternity Early Warning Scoring Systems (I-MEWS) allows a patient to be monitored using a standard guideline, coupled with a standardised escalating nursing, medical and multi-disciplinary response to be activated once complications are evident in a patient. A multi-disciplinary education and training programme in IMEWS has been rolled out across all 19 maternity hospital sites and a clinical guideline has been developed. Over 6,000 staff have been trained on the COMPASS programme for the early detection of deterioration in the patient’s condition. Training is compulsory in the National Early Warning score (NEWS) in intern training and is also part of undergraduate medical training.

Recommendation 2
Mandatory induction and education of all clinical staff working in obstetrics and gynaecology on the early recognition, monitoring and management of infection, sepsis, severe sepsis, and septic shock in accordance with appropriate clinical guidelines.

A multi-disciplinary team will be appointed to develop a national education and training programme for the management of obstetric emergencies; including the management of infection in pregnancy. This team will develop supporting resources for the introduction of guidelines on infection in pregnancy and provide training for staff on the guidelines.

Recommendation 2 also involves improved counselling services for women, husbands / partners following miscarriage and other serious incidents during pregnancy to ensure a standardised approach to counselling following a miscarriage. This requirement will be communicated to all 19 maternity units.

Recommendation 3
The HSE should develop, disseminate and implement national guidelines on infection and pregnancy. The HSE should also develop multidisciplinary educational programmes to improve the quality of care in pregnancies complicated by infection. Specifically, there is a need for the development, implementation and audit of compliance with guidelines on the management of infection in pregnancy, suspected sepsis and sepsis in cases of inevitable miscarriage of an early second trimester pregnancy including where there is prolonged rupture of membranes and where the risk to the mother increases with time from the time that membranes were ruptured.

In addition to the guidelines and training already referenced above; a National Medication Programme for Obstetrics and Gynaecology will be developed and implemented through collaboration with the HSE Clinical Programmes for Obstetrics and Gynaecology, the National Medicines Programme and other relevant Clinical Programmes. A clinical care pathway for the care of critically ill pregnant women is also currently being developed. This will deal specifically with the management of Obstetric emergencies including early recognition, monitoring and management of sepsis, severe sepsis and septic shock.

Recommendation 4a
Develop, implement and audit compliance with guidelines on the management of early second trimester inevitable miscarriage that are cognisant of the possible rapid deterioration of the patient from sepsis to severe sepsis to septic shock which could be within a few hours.

National guidelines have been developed on pre-term, pre-labour rupture of the membranes and these have been disseminated to all maternity hospitals. Work to complete the national care pathway on the care of critically ill pregnant woman is currently being finalised and will be disseminated to all maternity sites following consultation process.

The HSE will develop a national guideline setting out the correct procedures for the follow up of patient tests in hospitals.

Recommendation 4b
There is immediate and urgent requirement for a clear statement of the legal context in which clinical professional judgement can be exercised in the best medical welfare interests of patients.

The implementation of this recommendation is beyond the role of the HSE.

Recommendation 5
The HSE should implement and audit compliance with improved communication practices between all disciplines and grades of staff, and implement improvements in the handover for acutely ill patients including between staff shifts.

The HSE has established a working group to improve communications between all staff and disciplines in the management and handover of patient care. This will review and recommend the most appropriate tools to support clear and focused communication of information; particularly relating to the deteriorating patient.

Recommendation 6
Development, implementation and audit of compliance of guidelines in line with the Royal College of Obstetricians and Gynaecologists Guidelines on the “Responsibility of the consultant on call” (RCOG Good Practice No. 8 - March 2009).

This will be considered by the group established to improve communications between hospital staff, as referenced in Recommendation 5.