Actions of staff in Halappanavar case to be reviewed

The board of the West/North-West Hospitals group is to start a review of the actions of all staff members involved in the care of Savita Halappanavar after her admission to University Hospital Galway last year.

It said that if appropriate, individuals will be referred by the board to the Irish Medical Council (IMC) and the Nursing and Midwifery board, the board's chairman Bill Maher has said.

The two existing reports by the HSE, Health and Information Quality Authority (HIQA) and the coroner's inquest transcripts and findings would also be referred to these two regulatory bodies, he said.

Mr Maher says the board is already "co-operating fully" with preliminary hearings in some instances which are already being held by the two bodies.

Last week's HIQA report into Ms Halappanavar's death, after she was admitted to University Hospital Galway while 17 weeks' pregnant and miscarrying, identified 13 "missed opportunities" which, had they been identified and acted upon by the hospital, "may potentially have resulted in a different outcome for her".

Today’s statement from Mr Maher follows a special hospital board meeting last night at University Hospital Galway to review the HSE, HIQA and coroner’s inquest reports.

Its “review” of actions of all staff members involved in Ms Halappanavar’s care would “take account of, inter alia” these three investigations, and “as part of due process, the staff will have full opportunity to explain their decisions and actions,” Mr Maher said.

“We will take all appropriate action in light of these proceedings. I believe that in many instances there will be no case to answer,” he said.

"Patient safety is paramount for us all in the West/North West Hospitals Group and we are determined that we will learn from these three investigations and that we will take all action necessary to ensure the safety and welfare of all pregnant women and all other patients attending not just University Hospital Galway, but all the other six hospitals in our newly established group," he said.

Board chairman Noel Daly had placed on record at last night's board meeting an an apology to Mr Halappanavar and his family for "the events related to his wife's care that contributed to her tragic death," Mr Maher said.

Mr Maher said “considerable progress” had been made in implementing the recommendations from the HSE investigation and the coroner’s inquest.

These include the implementation of early warning scoring systems; the education of all staff in the recognition, monitoring and management of sepsis and septic shock;

the introduction of a new multi-disciplinary team-based training programme in the management of obstetric emergencies, including sepsis; the completion of specialist bereavement counselling training for key staff in the maternity unit; and improved communications procedures for doctors’ handovers.

“We will now also implement the HIQA recommendations and the board asked that they be given a detailed update on progress at each board meeting,” Mr Maher said.

“They also asked for an external review after 12 months of the implementation of the recommendations and, in the interests of full transparency, to make available the report from this audit at a public board meeting.

“The board emphasised that we should continue to apply all of the recommendations across the group and not just in University Hospital Galway,” he said.

"Many of the recommendations will have resource implications and the board has asked that we quantify these and advance discussions with the HSE and the Department of Health to ensure they can be implemented without delay," he said.

“No member of staff came to work during Mrs Halappanavar’s care or any other day to do harm,” Mr Maher said.

“ However, the death of Mrs Halappanavar had a devastating effect not just on her husband, family and friends but also on many people working at UHG. It also had a devastating effect on the trust that our patients have in our services,” he said.

The hospital board’s own governance structures, cross-committee membership and board composition, which had been criticised by HIQA, would also be reviewed, he said, and the board would “engage” with HIQA on this.

“I think people will understand that I am constrained in any further comments not just because of the ongoing IMC and NMBI enquiries, and our own disciplinary procedures that are about to start, but also that we need to be mindful that Mr Halappanavar has initiated civil proceedings against University Hospital Galway and a named consultant at the hospital,” Mr Maher said.