Three reports later and serious questions remain

So, after three inquiries, are we any wiser? Do we know why Savita Halappanavar died? And what does her death tell us about the wider state of maternity services in Ireland?

The first question is easier to answer than the second. Ms Halappanavar died in University Hospital Galway last October because of systems failures (the coroner's assessment), "multiple failures" to monitor her condition properly (the HSE report) or because of 13 "missed opportunities" in treating her that might have led to a different outcome (the Hiqa report).

The three inquiries vary in the degree to which they place blame specifically on the medical team, with Hiqa (the Health Information and Quality Authority) going furthest along this road by asserting “ultimate clinical responsibility” rested with her consultant obstetrician.

The details of how basic checks were not carried out during Ms Halappanavar’s week in the hospital have been covered in the various reports published this year and, unusually in such cases, the facts are largely undisputed. However, the extent to which blame is apportioned or fault found has yet to be determined on an individual basis.

There are valid arguments and counter-arguments as to whether this should happen. Publicly excoriating individuals lowers morale and deters whistleblowers, while failing to sanction people involved in serious errors can result in even lower standards and may let down the victims.

Regardless of the rights
and wrongs of these arguments, it seems likely that this case will end up before the Medical Council and/or other regulatory bodies.

Disputed issue
One issue remains disputed. When news broke of the case last year, most of the attention was on the hospital's refusal to accede to Ms Halappanavar's request for a termination.

At the inquest in April, the clinical director of the National Maternity Hospital, Dr Peter Boylan, argued that Ms Halappanavar would be alive today if she had been given the termination she asked for.

However, while this issue was mentioned in the HSE report – it recommended the Oireachtas consider the law and any necessary constitutional change to protect the life of a pregnant woman at risk – it did not feature at all in Hiqa’s. Both reports, however, focused in the main on the litany of basic medical errors.

Dr Boylan reiterated yesterday that the law on terminations "undoubtedly inhibited" the medical team in Galway from intervening when intervention by delivery would have saved Ms Halappanavar's life. It may take the civil suit being taken by Ms Halappanavar's husband, Praveen, to see this issue properly thrashed out and decided in a public forum.

As for the question of whether it is safe to have a baby in Ireland, there is no clarity. Even members of the Hiqa team appeared to diverge on this issue. One said women could be reassured that their babies would be delivered safely, while another pointed to the dearth of information that could provide such reassurance.

For the tiny minority of women needing emergency intervention during childbirth, the large-scale absence of critical care and high-
dependency beds in maternity hospitals may be a cause for concern, as it was for Hiqa.

The fact is we know little enough about what goes on
in Irish hospitals, not just maternity hospitals. Occasionally, a high-profile, tragic case comes along to help lift the veil but generally there is little publicly available analysis of clinical issues. Hiqa inspectors can enter nursing and care homes to assess standards, but have no equivalent role in the acute hospital system. That will have to await the arrival of a licensing system, promised in 2015 at the earliest.

Alarming revelation
Probably the most alarming revelation to emerge from the Hiqa report was the extent to which the health system has failed to learn from previous incidents. The Tania McCabe report, the Mallow Hospital report and the Lourdes hospital inquiry reports all made recommendations relevant to this case, and it does not seem they were implemented across the board. Some of these inquiries were the HSE's own investigations, and the failure to learn from past mistakes is apparent and alarming. The same can be said of inquests, which deal with medical mishaps on a regular basis, yet their findings are not analysed centrally.

The report raises the issue of resources and it is true
that Ireland is substantially under-provided with maternity staff. Yet, as Minister for Health James Reilly pointed out, no staffing issue can explain away the lack of basic clinical care that took place in Ms Halappanavar case.