Death of Savita Halappanavar

Death of Savita Halappanavar
Date 28 October 2012 (2012-10-28)
Location University Hospital Galway, Galway, Ireland
Cause Septicemia and multiple organ failure
First reporter Kitty Holland and Paul Cullen, The Irish Times

The death of Savita Halappanavar on 28 October 2012, at University Hospital Galway in Ireland, led to protesters calling for a review of the abortion laws in Ireland, which they claimed were responsible for her death. Halappanavar, a 31-year-old Indian woman, originally from Belgaum in the Indian State of Karnataka, was working in Ireland as a dentist. When she was 17 weeks pregnant, she sought medical attention and treatment at University Hospital Galway as she began suffering from a miscarriage, which was later assessed to most likely to have been triggered by a bacterial infection, which eventually killed her.[1][2]

Beginning no earlier than the date of her hospital admission, October 21, she repeatedly requested an abortion for her miscarrying fetus but was refused, instead being told by Katherine Astbury her obstetrician that as she then appeared physically well,[3] and her fetus had a heartbeat, her life did not appear to be in danger and therefore this was not legal.[3] After Ms. Halappanavar engaged in a conversation with her midwife Ann Burke, that in India and Hinduism abortions on request were possible, Ms. Burke commented that "this is a Catholic country" but later said it "had came out the wrong way" and it "had nothing to do with medical care at all".[3][4][5] On the night of October 23, according to her husband Praveen, Ms. Halappanavar was standing in a restroom and collapsed.[6] The following day October 24, the heartbeat of her foetus ceased,[3] and the remains were removed from her uterus in the operating theatre, at approximately the time that the results of her blood samples came back with a diagnosis of septic shock,[7] Savita Halappanavar's septicemia then further deteriorated despite being treated with oral antibiotics for infection since late October 22 and intravenous antibiotics since October 24.[8] Both were ineffective and her condition rapidly evolved to the point of organ failure and finally cardiac arrest and death on 28 October 2012.[4][5][9]

Halappanavar died at University Hospital Galway.

Soon afterward Ms. Halappanavar's husband and friends, who believed that had his wife had an abortion when she requested one she would be alive,[10][11] began contacting pro-choice groups in Galway.[10][11] Aided by pro-choice groups who had foreknowledge that her death was to be made into "major news related to the denial of abortion",[12] The news of Halappanavar's death spread rapidly through both traditional and social media outlets, with one of the original stories in The Irish Times on 14 November receiving over 700,000 hits by 17 November,[9][13][14] which exclusively contained Mr. Halappanavar's account of the tragedy.[15] Protests were held calling for a change in the abortion laws in Ireland, which protesters claimed had led to Ms. Halappanavar's death.[16][17] Indian diplomatic and consular officials requested an official inquiry into the events surrounding Halappanavar's death.[18] The United Nations Special Rapporteur for physical and mental health also became involved, saying abortion should be legal if a pregnancy is adversely impacting a woman's health.[19] However 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.[20][21]

The Health Service Executive (HSE) named Sabaratnam Arulkumaran, president of the British Medical Association to head a seven-member panel to investigate the case in 2012. The panel would seek to uncover all the facts and "to identify any safety issues arising in this case".[22]

In 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.[23][24]

The investigative report into her death was published in October 2013 and determined that had the patient received intervention with antibiotics as a prophylaxis immediately following the spontaneous rupture of membranes at 00:20 on October 22, instead of first administration occurring 21 hours later, then in the opinion of the investigative team the outcome would potentially have been quite different.[25] Some reports indicate that hospital protocols on early antibiotic treatment had not been followed.[3]

Mortality due to maternal sepsis is the leading cause of maternal death in other countries including Britain and its rate is increasing. Severe sepsis and septic shock are major worldwide healthcare problems, affecting millions of people, leading to a mortality rate of one in four, and is increasing in incidence worldwide. Studies have found that survival rates following sepsis are related to early recognition and initiation of treatment.[26]

In response to the media storm and pro-choice protests that resulted from her death, in which it was claimed that abortion could have saved her life,[27][28] and prior to the medical panels investigation being published, in July 2013 a Protection of Life During Pregnancy Act 2013 was signed into law by President Michael D. Higgins that permits abortion in Ireland if the mother is suicidal.[29] Some argue that the denial of abortion story was a convenient "smokescreen" to focus attention away from the protocol failures within the hospital, which should have suspected infection immediately upon admission to the facility and that Savita’s death was used by pro-choice elements to "grease the wheels of the Pregnancy Act", which would have had no effect on her had it then been in place.[30]

Background

Under previous Irish law, according to 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.[31] 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".[32] However this "suicide" clause had not been finalized in legislation at the time of Halappanavar's death.

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 is Irish law to save the life of the woman in such cases.[20][21]

Microbiologist Dr James Clair[33] stated that the "main problem is being missed" in the case, and the real issue was 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.[34]

Reaction

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,[30] on November 7.[10][11]

Three days before the story was made known to the public and it became "major news",[12] "Andrew B" of the Irish Choice Network (ICN) - a group set up to link pro-choice persons and groups - began an online discussion aimed at inviting senior ICN individuals to a meeting in Dublin on how they would organize their "collective decisions" on an incident they had been tipped-off was going to be formed into a "major news story related to denial of abortion access" which was "to break in the media early this coming week".[12] On Monday an ICN responder requested that any "decisions taken" by the group to be circulated to members by email as not everyone could make the meeting on short notice.[12] When questioned later by a reporter who uncovered the groups illuminating foreknowledge, this latter member replied "I am not going to give a comment I'm afraid".[12]

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.[13] 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.[13]

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.[35] In addition, a candle-light vigil was held in Cork.[9]

Savita Halappanavar's death led to protests in Galway, particularly from the local Indian expatriate community.[36] On 14 November The Mirror reported that the University Hospital was the subject of several investigations.[15] Halappanavar had been one of the organisers of the annual Galway Diwali festival, which was cancelled in response to her death.[4]

There were calls upon the Taoiseach to secure an external enquiry into the circumstances surrounding Ms. Halappanavar's death.[9] 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".[4] On 16 November, the Irish Health Service Executive established an independent inquiry into the circumstances surrounding Halappanavar's death.[37]

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.[38]

On 17 November, Gardaí announced that they were assisting the coroner in the investigation into the death of Halappanavar.[39]

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.[20]

On Monday, 19 November, the Catholic Bishops of Ireland met in response to Savita 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.[40]

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."[41] 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."[42]

On 18 November, the Sunday Independent obtained the discussion by ICN members that details that the story of her death was intended to be made into a "major news story related to denial of abortion access".[12]

Response from the medical community

The staff of University Hospital, as well as members of Ireland's HSE Regional Health Forum, have stated that there is no "Catholic ethos" that is impacting treatment provided.[43]

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."[44][45]

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."[46]

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."[47]

Microbiologist Dr James Clair[33] 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.[34]

Political response in 2012

Taoiseach Enda Kenny, stated: "I don't think we should say anything about this until we are in possession of all the facts."[48]

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.[49] He has also stated that an inquiry into Halappanavar's death must stand up to international scrutiny.[50]

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".[51]

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]".[52] 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."[53]

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.[54] 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 it's 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.

Irish Choice Network allegedly emailed members, calling for an emergency meeting to discuss how to proceed with this "major news story".[55]

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."[56]

Response of pro-life organisations in 2012

The Life Institute in Ireland has accused what it called "abortion campaigners" of exploiting Halappanavar's death to further the pro-choice agenda.[57]

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."[58]

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."[59]

International response

There were protests outside the Irish embassies in London,[9] Berlin[60][61] and Brussels.[62]

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.[63] 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.[64]

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!"[65]

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."[66]

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."[67] 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."[67]

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.

The panel sought to uncover all the facts and "to identify any safety issues arising in this case".[22]

On 20 November 2012, three members of the panel were asked to step down when 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.[68] 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.[69]

Arulkumaran report

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.[1] 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."[1]

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.[1]

Recommendations of the Panel

  1. 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.[70]
  2. Introduction of mandatory induction and education on early recognition, monitoring and management of infection and sepsis. This includes severe sepsis and septic shock.
  3. 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.
  4. Two sub-recommendations:
    1. 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.[71] 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.[72]
    2. 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.
  5. 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).[72]
  6. 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.[72]

Aftermath

Partly in response to the protest movement after the death of Savita Halappanavar,[27][28] 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.[29]

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.[23][24]

HIQA report

The Health Information and Quality Authority (HIQA) published a report into the incident on 9 October 2013.[73] 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".[74][75][76]

See also

Sources

References

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  56. ↑ Kate Smurthwaite: (15 November 2012). "Yes, Savita Halappanavar's Death IS a Political Issue". Huffington Post. Retrieved 19 November 2012.
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  58. ↑ "After Tragedy, Irish Abortion Laws Come Under Fire". The Catholic World Report. 15 November 2012. Retrieved 19 November 2012.
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  61. ↑ "Vigil for Savita and Protest at Ireland’s Abortion ban, Irish Embassy, Berlin". Midi Grrrl. 21 November 2012. Retrieved 29 November 2012.
  62. ↑ "Last night in Brussels". Broadsheet.ie. 22 November 2012. Retrieved 12 February 2013.
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  64. ↑ "Salman Khurshid closely following developments in Savita Halappanavar death case". The Times of India. 18 November 2012. Retrieved 19 November 2012.
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  66. ↑ "Savita's kin being consulted". The Times of India. 17 November 2012. Retrieved 19 November 2012.
  67. 1 2 Press Trust of India (17 November 2012). "Irish Government must clarify on abortion issue: Amnesty". The Times of India. Retrieved 17 November 2012.
  68. ↑ "HSE announces Savita inquiry team replacements". Irish Times. 21 November 2012. Retrieved 22 November 2012.
  69. ↑ O'Regan, Eilish; Harkin, Greg (21 November 2012). "Probe into Savita shambles goes from bad to worse". Irish Independent. Retrieved 21 November 2012.
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  75. ↑ Damning Savita report details litany of hospital care failures
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