The real story of Savita’s tragic death

Last year the death of an Indian woman was exploited as an example of Ireland’s “archaic” abortion laws. But the under-reported inquest tells a different story.

The inquest into the tragic death of Savita Halappanavar has reached a verdict of “medical misadventure”. However, this was not the view of opponents of Ireland’s pro-life laws and those with an anti-Catholic or militant secular agenda. Catholic dogmatism, they have claimed, was responsible for the death of a pregnant woman from sepsis.

The media narrative is that Savita Halappanavar died because she was denied a life-saving abortion. The right to life of her unborn child trumped her own right to life. One tweeter produced the evidence: a religious statue outside the hospital where Savita was treated.

Whilst the Irish constitution guarantees to respect and defend the life of the unborn child, stating that the lives of mother and child are of equal value, Ireland is also one of the safest places in the world in which to give birth. It boasts maternal death rates that are 33 times lower than Savita’s home country of India, and 3.5 times lower than the US. Pro-life Chile has the lowest maternal death rates in Latin America, and Poland, another pro-life country also fares well. Countries which respect the life of the unborn also ensure the highest standards of medical care for pregnant women.

The progress of septic shock

Savita Halappanavar died from septic shock resulting from an E.coli bacterial infection which had entered her bloodstream via the urinary tract. The Royal College of Obstetricians and Gynaecologists (RCOG) has attributed most of the deaths of pregnant women in the UK with a baby under 24 weeks gestation, from sepsis, as being due to “substandard care… in particular a lack of recognition of the signs of sepsis and a lack of guidelines on the investigation and management of genital track sepsis”.

Severe sepsis of the type that killed Savita has a mortality rate of 60 percent. The RCOG’s 2012 green top guidelines note that early recognition of symptoms and initiation of treatment are vital when it comes to increasing patients’ chances of survival. The diagnosis of sepsis must be confirmed by blood cultures and early swift administration of broad spectrum antibiotics is the key to the survival of the patient, together with regular monitoring.

Savita Halappanavar first presented at University College Hospital Galway on the afternoon of Sunday, October 21, with backache but she was sent home following an examination. Savita had a history of back problems. She returned later that evening having experienced blood loss and was admitted. A blood sample was taken.

Crucially, the results of the blood tests, which showed an elevated white blood cell count indicating that an infection was present, were never followed up. The inquest heard that though the results were processed almost instantaneously, the first time they were accessed was some 24 hours later by an unidentified member of staff, and later by Dr Katherine Astbury, the consultant in charge of her care, at 11.24 on the Wednesday morning. This was five hours after she had been diagnosed with sepsis and after her condition had rapidly deteriorated.

Speaking at the inquest, Dr Astbury stated that if she had had access to the blood results earlier, she would have taken measures to terminate Savita’s pregnancy on the Monday or the Tuesday. However, she had been judging Mrs Halappanavar on the basis of clinical signs only and it had been her opinion that Savita was “distressed, but not unwell”.

Delay, not dogma, was the problem

It is difficult to see how Irish law, let alone Catholicism, should be held to account for this delay in diagnosis. Irish law allows for an unviable pregnancy to be terminated in the event that a mother’s life might be at real and substantial risk; sepsis would certainly fall into that category. A real and substantial risk does not need to be immediate, as with an ectopic pregnancy. The question is whether the woman will die if an abortion is not performed.

A bacterial infection needs to be aggressively targeted by broad spectrum antibiotics administered intravenously. Following her admission into hospital, Savita’s membranes had spontaneously ruptured very late on the Sunday evening. Her cervix was thought to be fully dilated, leading the staff to believe that delivery was imminent. The ruptured membranes put Savita at a 30-40 percent increased risk of infection and on Monday she was given a course of oral antibiotics as a precaution.

The burden of proof for infection in this situation is low. However the inquest discovered that vital four-hourly observations were missed, in addition to the failure to monitor her blood results. Regular blood tests to identify trends in white blood cell count and observations of her vital signs would have constituted optimal care, but this did not occur.

Furthermore, it was not until 1pm on Wednesday, October 24, that the correct broad spectrum antibiotics to target the infection were administered. Prior to this, Savita had been given erythromycin, a variant that was resistant to the E.Coli infection which was rapidly spreading throughout her body.

In addition, a lactate serum test which could have definitively confirmed the presence of sepsis was taken at 6am on the Wednesday morning and stored in an inappropriate bottle before being sent to the lab which could not process it. Even if the sample had been stored correctly, the lab would have been unable to analyse the test which should have been performed at a point of care unit on the ward.

The inquest heard that after 1pm on Wednesday, October 24, when Savita was taken into theatre where she spontaneously delivered her deceased child, and was then admitted to a high dependency unit, she received the highest possible standard of care. But there had been significant failures prior to this.

Did her survival hinge on a termination?

Opinion is divided as to whether or not a termination would helped Savita. The presence of an infection is a contraindication to surgical intervention, because the clamps and forceps required in a procedure risk further infection.

Furthermore Savita’s unborn child was not the source of her bacterial infection, the uterus and membranes being a sterile environment. Use of the drug misoprostol to contract the uterus and expedite delivery would not have guaranteed that the process would have been any swifter nor ruled out the necessity for surgery.

Conservative management is the preferred clinical approach in cases of spontaneous miscarriage. In the absence of obvious signs of infection, masked by her painkillers, it is not surprising that the medical staff decided that intervention was unnecessary. With ruptured membranes and a dilated cervix, it was perfectly reasonable to assume that nature would soon take its course. The outcome for the baby would have been tragically inevitable, but there would have been no long term ill-effects for the mother.

A failure of communication

Another troubling aspect of Savita’s case was failure to communicate the reasons for the hospital’s approach. Upon learning that a miscarriage was inevitable, Savita requested a termination so that she could leave the hospital as quickly as possible. Her parents had been visiting her and were about to leave the country. She wanted to be able to say goodbye to them at the airport.

Dr Astbury refused the request, couching this in purely legal terms, stating that Irish law did not allow for abortion.

This response was a cause of much distress for Savita and her husband Praveen. A discussion ensued with Ann Maria Burke, a midwife on duty, as to why abortion is banned in Ireland, unlike India. In response to Savita’s assertion that India was a Hindu country, Ms Burke replied that Ireland is a ‘Catholic country’ by way of explaining the background to the law.

Ms Burke has apologised. But the damage was done. Savita and Praveen blamed Irish law and Catholicism for the hospital’s unwillingness to do an abortion and the remark was seized upon by pro-abortion campaigners after her death. But whatever Ms Burke meant, she was not in charge of determining the appropriate course in Savita’s case.

Should the law be changed?

At the inquest, Dr Peter Boylan, an expert witness with a publicly stated position in favour of relaxing Irish laws on abortion, laid the blame solely on the legal position. He opined that were abortion legal in Ireland, Savita would have been alive today.

In recording a verdict of medical misadventure the inquest jury implicitly repudiated this. Instead it accepted and endorsed the coroner’s recommendations which emphasised a tightening up of procedures to remedy acknowledged systems failures.

Instead of recommending that the law should be reviewed, the jury said that the Irish Medical Board guidelines should be more explicit in describing the circumstances under which a woman’s life might be considered to be at risk.

The response from Galway University College Hospital seems to accept this, with no mention that the law had put doctors in an impossible position. Savita’s husband also seems to have rejected Dr Boylan’s analysis. When interviewed by the Irish Times after the verdict, he expressed exasperation at Dr Astbury’s conduct. He said that the world of obstetricians was a small one and suggested that the law was being used as a convenient shelter.

It is certainly difficult to see how the law is at fault for the initial failures in Savita’s care. Every year in Ireland there are 14,000 miscarriages, many of them carrying an infection risk, and no maternal deaths on record where the obstetrician felt that the law was inhibiting them.

Dr Sam Coulter Smith, master of the Rotunda Hospital in Dublin, says that he has terminated a pregnancy in four instances where women had been diagnosed with sepsis and in all of them the baby did not survive. In any event, there is no evidence to suggest that the hospital staff believed that they had a desperately ill patient or that they were waiting until her condition became critical.

The coroner explicitly stated that the verdict did not mean that the blame for Savita’s death should be solely attributed to systems failures at University College Hospital Galway. Sepsis is still a very rare occurrence, as is spontaneous second trimester spontaneous foetal abortion. This occurs in 0.5 percent of single pregnancies of women with no previous history. In the last 40 years in Ireland there have been five cases of septic abortion. Its detection relies upon staff being alert to its possibility and symptoms.

Savita was the first maternal death in 17 years at the hospital, as opposed to the 100 mothers who have died in childbirth in London in the last five years. Once sepsis has taken hold, its spread is incredibly difficult to control. Hindsight is a wonderful thing, but there is no guarantee that Savita would have survived even with the highest standard of care.

A background of austerity

What perhaps is of more relevance is that concern had been expressed about the hospital’s overall performance. In two successive months in 2011 it had been named as Ireland’s worst performing hospital. There had been calls for the Irish health minister to intervene.

It is far more likely that the austerity measures imposed upon Ireland, leading to an over-stretched and under-resourced maternity department, had far more impact upon Savita’s care. This is not what Ireland’s Taoiseach, Enda Kenny, currently engaged in a war of words against Catholicism in what some believe to be a diversion away from his party’s handling of the economy, wants to hear.

Savita Halapannavar has become the poster girl for Ireland’s abortion advocates. It will be a terrible irony if her legacy is more tragic deaths of the unborn. Far more fitting would be the successful implementation of precautions to prevent more deaths from sepsis. Anyone looking to improve maternal safety would be wise to highlight the dangers of E. Coli bacteria and the measures that women should take to avoid infection.

Cross-posted from MercatorNet from a post by Caroline Farrow