Death of Savita Halappanavar
|Date||28 October 2012|
|Location||University Hospital Galway, Galway, Ireland|
|Cause||Septicemia and multiple organ failure|
Savita Halappanavar, a 31-year-old dentist, died on 28 October 2012, at University Hospital Galway in Ireland, due to complications of a septic miscarriage at 17 weeks gestation, after being denied an abortion.
Under the law in force at the time, the Offences against the Person Act 1861, as amended, the act of abortion, where there is no immediate physiological threat to the woman's life to continue the pregnancy, is a criminal offence punishable by imprisonment. Following a ruling of the Supreme Court of Ireland in 1992—now known in Ireland as the X case—terminations are allowed under certain circumstances, where "a pregnant woman's life was at risk because of pregnancy, including the risk of suicide". However at the time of Halappanavar's death there was legal uncertainty regarding the precise circumstances in which this exception to preserve the life of the mother would apply in practice, as the matter had not yet been clarified by legislation.
Medical terminations had previously been performed at the University Hospital when life-threatening complications had clearly arisen in pregnancy, including cases a year previous to Halappanavar's death, as it was consistent with Irish law to save the life of the woman in such cases.
Savita went to the hospital with her husband Praveen on 21 October 2012 complaining about back pain. Her water broke early on the morning of October 22 and Savita asked if anything could be done to save the baby. She was told that the miscarriage was inevitable. On October 23, having understood the baby would not survive, she asked for a termination, and was told it was not legally possible in Ireland while there is a foetal heartbeat. Midwife manager Ann Maria Burke attempted to calm an upset Savita and explained that the termination cannot be carried out because Ireland is "a Catholic country", a statement she later said was not meant in a hurtful way and was sorry if it sounded bad now. In preparation for a termination on the 24th of October, Savita delivered a dead baby girl. At 1:09am, on Sunday 28 October, Savita died.
On 3 November 2012, friends and family of the Halappanavars contacted local pro-choice groups (Galway Pro-Choice) to find out what they could do, with dozens of her friends and family meeting in person on the 6th. Galway Pro-Choice put them in contact with the Irish Times journalist Kitty Holland, on November 7.
Savita Halappanavar's death became public after the Tonight with Vincent Browne programme showed front-page stories by The Irish Times and the Irish Independent newspapers on 13 November 2012. This resulted in the news being disseminated on Twitter, including by journalists Caitlin Moran and India Knight, and being covered by publications such as BBC News, the British edition of The Huffington Post, and The Guardian, The Daily Telegraph, Daily Mirror, The Independent and the Daily Mail newspapers.
On 14 November 2012, more than 2,000 people gathered in her memory and to protest Ireland's abortion laws outside the Dáil in Dublin. In addition, a candle-light vigil was held in Cork. The government's expert committee in abortion handed in its report to the Department of Health the day before.
Halappanavar's death led to protests in Galway, particularly from the local Indian expatriate community. On 14 November The Mirror reported that the University Hospital was the subject of several investigations. Halappanavar had been one of the organisers of the annual Galway Diwali festival, which was cancelled in response to her death.
There were calls upon the Taoiseach to secure an external enquiry into the circumstances surrounding Ms. Halappanavar's death. There are also calls for a change in the law, as the present legislation is an Act of the British Parliament of 1861—when Ireland was still part of the United Kingdom —which declares that it is unlawful to "procure a miscarriage". On 16 November, the Irish Health Service Executive established an independent inquiry into the circumstances surrounding Halappanavar's death.
On Saturday 17 November, the Garda Síochána (Ireland's national police) estimated that between ten and twelve thousand protesters marched from Parnell Square to Merrion Square to demand a change in the law, whilst other rallies were also held across Ireland and in many other countries abroad.
On 17 November, Gardaí announced that they were assisting the coroner in the investigation into the death of Halappanavar.
Medical terminations had previously been performed at the University Hospital when complications had arisen in pregnancy, as it is permitted by Irish law to save the life of the woman. In an opinion piece in the Daily Mail, Paul Bracchi speculated that an investigation would be carried out into why this did not occur in Halappanavar's case.
On Monday, 19 November, the Roman Catholic Bishops of Ireland met in response to Halappanavar's death and released a statement that the Catholic Church believes in the "equal and inalienable right to life of a mother and her unborn child" and that the Church has never taught that the life of an unborn child takes precedence over the mother.
Eilis O'Hanlon stated that in its initial coverage, The Irish Times had "opted to present what had happened as a simple morality tale" and that "the debate for the rest of the week was coloured entirely by The Irish Times's decision to reduce a complex personal tragedy, about which few facts were still known, to a rallying call." An analysis in The Irish Times on 17 November stated: "There is much we do not know about the medical care Savita Halappanavar received" and "even before the full facts are established Ms Halappanavar’s tragedy has generated much national and international coverage" in both traditional and social media of which some has been "careful and sympathetic" but "much ... has been intemperate, intolerant and politicised."
Response from the medical community
Dr Sam Coulter-Smith, a consultant in obstetrics and gynaecology and a university master in the Rotunda Hospital, one of the biggest maternity hospitals in Ireland, said that it would be preferable to introduce legislation to bring in clarity, saying, "We really do need legislation in this area, otherwise we're going to be at risk of doctors working outside the law, and that's not appropriate."
Dr Rhona Mahony, Master of the National Maternity Hospital, said: "It is very disappointing that, 20 years after the 'X-Case', we don't have legislation" and that women "need to know that they are going to get the appropriate health care that they need" while doctors "need to know that they are also protected in their ability to do their job."
Peter Boylan, of the Irish Institute of Obstetricians and Gynecologists, said: "The current situation is like a sword of Damocles hanging over us. If we do something with a good intention, but it turns out to be illegal, the consequences are extremely serious for medical practitioners."
Microbiologist Dr James Clair stated that the "main problem is being missed" in the case, suggesting that the real issue may be that the septicemia was caused by extended-spectrum beta-lactamase positive gram negative bacteria (ESBL), which "are now spreading rapidly within the Irish population" and are resistant to many known antibiotic treatments.
Political response in 2012
Prior to publications of the reports, the Minister for Health, James Reilly, said that the public must not pre-judge the situation and further said that he was awaiting the results of the investigations, adding he had no evidence to suggest a so-called "Catholic ethos" at the University Hospital that prevented Halappanavar's life from being saved by a medical termination. He has also stated that an inquiry into Halappanavar's death must stand up to international scrutiny.
Brian Walsh, a Fine Gael TD for Galway West, said that Galway University Hospital had carried out terminations in recent years in accordance with the judgement by the Supreme Court in the X case and with the guidelines of the Irish Medical Council. He said that the University Hospital was not run or managed by any [Catholic] religious orders and did not have a so-called "Catholic ethos".
Fianna Fáil leader Micheál Martin said that Halappanavar's death was tragic and harrowing. Martin said that Ireland had always aimed for a low death rate during pregnancy but that this was "cold comfort" to Halappanavar and her surviving family and relatives. He said that an independent inquiry was needed, with experts from outside the country to establish the full circumstances. He also responded on Saturday 17 November saying that "legislating for the X case would not have stopped [the death of Savita Halappanavar]". On 18 December 2012, after a panel of experts submitted its report to the Parliament recommending, "the government legislate the issue in order to clarify what the current laws actually do and do not permit", Ireland’s then Minister of Health, James Reilly, stated "We will clarify in legislation and regulation what is available by way of treatment to a woman when a pregnancy gives rise to a threat to a woman’s life."
Response of pro-choice organisations in 2012
Pro-choice campaigners highlighted at the time that the lack of legislation clarifying the limited circumstances in which abortion is legal in Ireland caused Halapanavar's death. Several rallies and vigils were organised nationwide, calling for the Irish government to legislate in relation to abortion on the basis of the X Case Attorney General v. X. Campaigners argued that legislation remained outstanding at the time of Halappanavar's death despite the European Court of Human Rights having instructed the state to clarify its laws on abortion after finding in A, B and C v Ireland (2010) that the Republic of Ireland had violated the Convention by failing to provide an accessible and effective procedure by which a woman can have established whether she qualifies for a legal abortion under current Irish law.
In response to critics accusing pro-choice activists of exploiting Halappanavar's death, Kate Smurthwaite responded in a column in the Huffington Post called "Yes, Savita Halappanavar's Death IS a Political Issue" in which she stated, "If I am ever a victim of an unjust legal discrepancy that infringes my human rights and leads to my untimely and unnecessary agonising death I want every man, woman and child on the streets immediately demanding that it never, ever be allowed to happen again."
Response of pro-life organisations in 2012
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and the Catholic Church
Michael Kelly of The Catholic World Report rejects claims that Ireland's abortion laws led to Halappanavar's death, writing that "medical experts and bioethicists have been quick to express their view that Ireland's ban on abortion had nothing to do with Mrs. Halappanavar’s death. They insist that guidelines from the Irish Medical Council are perfectly clear that pregnant women must be given all necessary medical treatment."
Father Shenan J. Boquet, president of Human Life International, said that there was no evidence to indicate that "a Catholic ethos" prevented responsible treatment of the mother, and called news reports that that was the case "demonizing the church's position on abortion". He described the debate resulting from the event as "activism masquerading as compassion and moral outrage."
In India, the Indian Minister for External Affairs, Salman Khurshid, summoned the Indian ambassador to Ireland, Debashish Chakravarti, to India for deliberations over the issue. Chakravarti later met Eamon Gilmore, Ireland's Tánaiste (deputy prime minister) and foreign minister, and promised to keep Halappanavar's husband up to date with the government's response.
Rajeev Chandrasekhar, an independent member of the Rajya Sabha (the upper house of the Parliament of India) said, "The death of Savita Halappanavar should be pursued by family and Govt. of India as a case of human rights violation and murder. Instead of simply protesting, cases should be filed against the Govt. of Ireland and its leadership at the International Court of justice and United Nations Commission for Human Rights UNHCR. This should move beyond protesting to where people are brought to account!"
In an editorial on 17 November 2012, The Times of India said, "There appears to be a tendency to view this issue in terms of India versus Ireland or the Catholic faith against other religions. To fall prey to such tendencies would be a serious mistake and a great disservice to the memory of Savita. ... Adding a nationalist or communal tone to the debate detracts from the merit of argument rather than enhancing it."
Amnesty International states that Halappanavar's death "illustrates [the] gap in Irish law" and asked the government of Ireland to change the law on abortion "in line with international human rights laws." The executive director of Amnesty International in Ireland, Colm O'Gorman, said that "successive Irish Governments have failed in their duty to provide necessary clarity on how this right is protected and vindicated, leaving women in Ireland in a very vulnerable position."
HSE inquiry 2012
On 19 November 2012, the Health Service Executive (HSE) named Professor Sir Sabaratnam Arulkumaran to head a seven-member panel looking into the case. Arulkumaran is the head of obstetrics and gynaecology at St George's Hospital Medical School and is president-elect of the International Federation of Gynaecology and Obstetrics.
On 20 November 2012, three members of the panel were asked to step down when Savita Halappanavar's husband, Praveen Halappanavar, indicated that he would not cooperate with the panel due to their connections as consultants to University Hospital. Arulkumaran has requested a meeting with Mr. Halappanavar. On 21 November, the Irish Independent reported that Arulkumaran was being accused of being "pro-abortion" and promoting a "liberal" approach to abortion because of papers that he has published.
The Arulkumaran report was published on 13 June 2013. It identified three "Key Causal Factors" for the death: inadequate assessment and monitoring; failure to offer all management options to a patient; and non adherence to clinical guidelines related to the prompt and effective management of sepsis. It made six recommendations for improvements in patient care in such situations. Most recommendations called for improvements in healthcare guideline, training and practices, and one recommendation called for legislative changes if necessary to allow for expediting delivery for clinical purposes. Additionally, it made three recommendations to address incidental factors.
Key causal factors
The report indicates the first key causal factor was inadequate assessment and monitoring. This would have allowed medical staff to recognise and respond to indicators that the infection was causing a deterioration in Savita's condition. Additionally, staff failed to devise a plan of care recognising that: (1). Infection was the most likely cause of the patient's miscarriage, and, (2.) With increase in time following admission, and the rupture of the patient's membranes, the risk of infection and sepsis increases.
The panel identified the hospital's failure to offer all management options to a patient was a second key causal factor. The panel points out that the patient was "experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to the mother increased with time from the time that membranes were ruptured."
The panel found that hospital staff failed to adhere to clinical guidelines which relate to severe sepsis and septic shock. These relate to timely and effective management of sepsis when it is diagnosed.
Recommendations of the Panel
- Prompt introduction of a Maternity Early Warning Scoring Systems Chart for patients with pregnancy complications in gynaecology wards. This should be followed by a compliance audit. The chart should indicate a monitoring coupled with an escalating nursing, medical and multidisciplinary response.
- Introduction of mandatory induction and education on early recognition, monitoring and management of infection and sepsis. This includes severe sepsis and septic shock.
- Development and implementation of national guidelines relating to infection and pregnancy, in addition to multidisciplinary educational programmes to improve care in such cases. In particular, there needs to be audited compliance with guidelines on management of infection, sepsis, and suspected sepsis in cases of inevitable miscarriage of an early second trimester pregnancy. This includes when there is a prolonged rupture of membranes, and increasing time from this point increases the risk to the mother.
- Two sub-recommendations:
- Compliance with guidelines on the management of early second trimester inevitable miscarriage. This should recognise possible rapid patient deterioration, possibly within a few hours, from sepsis to severe sepsis to septic shock. It should also recognise the high mortality rate, of up to 60 percent, associated with this. These guidelines should include the same emphases as those for infection and pregnancy listed in recommendation 3. The panel recommended such guidelines should include guidelines relating to expediting delivery for clinical reasons, including "medical and surgical termination" based on the expertise available and legal feasibility.
- Clear statement of the legal context in which clinical professional judgement can be exercised in the best medical welfare interests of patients. The Oireachtas should consider the law including any necessary constitutional change and related administrative, legal and clinical guidelines in relation to the management of inevitable miscarriage in the early second trimester of a pregnancy.
- The panel recommended improved communication practices between all relevant staff, and improvements in handover of acutely ill patients. Additionally, definitive tools for clearly communicating information relating to the deterioration of a woman's condition, consultation and/or handover to a higher level of care, according to ‘Improving patient handover – RCOG Good Practice No 12’ (Dec 2010).
- Compliance of guidelines on the consultants' responsibilities, according to the Royal College of Obstetricians and Gynaecologists, “Responsibility of the consultant on call” (RCOG Good Practice No. 8 - March 2009). These indicate the need to involve senior medical staff due to difficulty coping with case load, or to consult on suspected serious cases. Midwives and nurses should be able to obtain help from senior nurse midwifery managers or the director of nursing on duty, and need to be able to contact the consultant if needed.
Partly in response to the protest movement after the death of Savita Halappanavar, the Irish government introduced the Protection of Life During Pregnancy Act 2013. Having passed both Houses of the Oireachtas in July 2013, it was signed into law on 30 July by Michael D. Higgins, the President of Ireland.
On 20 September 2013, Praveen Halappanavar's solicitor served legal proceedings against Galway University Hospital and separately against Dr Katherine Astbury. The proceedings claim that Savita's constitutional right to life had been breached and allege 30 issues of medical negligence.
The Health Information and Quality Authority (HIQA) published a report into the incident on 9 October 2013. It found "following the rupture of her membranes, four-hourly observations including temperature, heart rate, respiration and blood pressure did not appear to have been carried out at the required intervals", noting "that though [University Hospital Galway]UHG had a guideline in place for the management of suspected sepsis and sepsis in obstetric care, the clinical governance arrangements were “not robust enough to ensure adherence to this guideline".
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