The final hours of Savita Halappanavar’s life were recounted by the intensive care nurse who cared for her.
Jacinta Gately said when she came on duty at 8pm on Saturday October 27th, Ms Halappanavar’s blood pressure was “unrecordable”, her heart rate was 150-55 beats per minute, she was intubated, ventilated and sedated with morphine.
“I was made aware that Ms Halappanavar’s husband Mr Halappanavar was in the waiting room with friends and was anxious to see his wife,” she said. At about 9pm an arterial line was inserted and her heart rate occasionally dropped from 150 bpm to 90 bpm. Her blood pressure was very low, she explained.
“Adrenaline and nor-adrenalin infusions were increased until her blood pressure improved,” she said. Tests found her lactate was now “very high” at 24, up from 8am on Thursday morning and grossly exceeding desireable levels of 1.5, she explained. The inquest heard earlier high lactate levels were an indicator of sepsis and anything above 4 an indicator of severe sepsis.
“Ms Halappanavar was unresponsive during this time, her pupils were very sluggish, size 4 – 5 and there was no response to stimuli,”Ms Gately said. Her body was also very swollen. “She was very oedematous, fingers flexed tightly, feet extended and very stiff. Her abdomen was very distended,” Ms Gately said. She had heavy vaginal bleeding, she said.
“I went to the waiting room to meet Ms Halappanavar’s husband Praveen at some time between 21.30 and 22.00. I apologised for keeping him and his friends waiting. I explained what we had been doing and brought him and some friends in to see Ms Halappanavar. They stayed a little while with Ms Halappanavar and left again. Dialysis had started by this time,” she said.
At about 10 pm, she said, alarms on the ventilator began ringing. Ms Halappanavar was given an intravenous infusion of Cisatracurium, a drug to relax her skeletal muscles in an effort to help her breathe, she said. At 11 pm Ms Halappanavar “remained unresponsive”, she said.
A system to monitor her level of consciousness found her at between 1 and 4, when ‘awake’ levels would be 100, she explained. Her blood pressure remained very low, while her lactate levels were continuing to rise, she said.. At 11.45 pm sodium bicarbonate, dextrose and insulin were infused in an effort to treat rising potassium levels and her abnormal heart rythms, she explained.
“Mrs Halappanavar’s husband and friends had been coming in and out for a few minutes. Each time I kept them informed of Mrs Halappanavar’s critical condition,” said Ms Gately.
“At 12 midnight approximately she was washed and blood-stained pads renewed.” She said whenever they turned Ms Halappanavar, her heart-rate increased from 140 bpm to 190 bpm. “So we stopped and let her heart settle.”
Between 12.30am and 12.45am, she and two colleagues were sitting by Ms Halappanavar’s bed. The monitor showed her heart rate had become chaotic, with a “broad spectrum rhythm”, Ms Gately said.
“Pulses were checked. None were palpable. CPR commenced by Dr Aoife Quinn, staff nurses Veronica Rafftery, Therese Connolly, Jeurgen Schone and Aine Nic an Bheath and myself,” she said. “Within minutes of commencing CPR I went out to find Mr Halappanavar to let him know what was happening, that his wife’s heart had stopped and that we had started CPR,” she said.
Mr Halappanavar, who was sitting alone at the back of the court, bowed his head, his eyes closed. Ms Gately asked for a glass of water. “I asked him if he wanted to be present while this was going on and he replied that he did. I explained that it would be very difficult for him. A friend accompanied him for support,” she said.
“CPR continued until after 0.1.15 when a decision was made to cease compressions as Ms Halappanavar was not responding to our efforts,” she said.
“Dr Quinn informd Mr Halappanavar that his wife was unresponsive and that she had passed away. Time of death recorded at 01.09 hours,” Ms Gately said.
As she sat back in her seat in the court, a medical colleague reached over to stroke her lap.
Praveen “forgives” midwife
Earlier speaking outside the inquest Praveen Halappanavar has said he forgives midwife manager Ann Maria Burke for saying to his wife Savita she could not get a termination "because Ireland is a 'Catholic country".
Speaking outside the inquest into her death, Mr Halappanavar expressed surprise and said he was “extremely grateful” to Ms Burke for telling the inquest she had used the term “Catholic country” and “Catholic thing” to his wife Savita when explaining why she could not have a termination.
“We never expected that. We thought she would deny it,” he said. "I was moved when she said that [she had used the "Catholic country" term]. I was relieved."
He said following the denial by consultant Dr Katherine Astbury that she had used the term “Catholic country” that he thought Ms Burke would too. He remains adamant Dr Astbury did use the term.
“She said that to us on day one, on Monday morning. There was another midwife there at the time but I just cannot remember her name. I wish I could remember her name. There were just so many people during that week.”
Asked whether he forgave the remark, he said "I do".
His solicitor, Gerard O'Donnell, said a meeting with the chairman of the HSE clinical review into her death will not take place until after the inquest is over.
He said they wanted the benefit of all the evidence from the inquest before discussing the HSE's draft final report.
Ms Burke had previously acknowledged that she made the remark to Ms Halappanavar when she was miscarrying but there was still a foetal heartbeat.
Regret expressed
In evidence to the inquest yesterday, she expressed regret about the remark but explained that it wasn’t intended to be hurtful.
“It was not said in the context to offend her. I’m sorry how it came across. It does sound very bad now but at the time I didn’t mean it that way.
“ It was the law of the land and there were two referendums where the Catholic Church was pressing the buttons.”
Meanwhile, the inquest heard this morning that Ms Halappanavar’s outlook was “very poor” by 9am on Thursday, October 25th, two days before she died.
Consultant anaesthetist Dr John Bates, who was involved in her care from that time, said she was then in “severe respiratory distress” due to lung dysfunction, resulting from severe sepsis.
He said her lactate levels were elevated - another sign of sepsis - and her clotting was “abnormal”.
“Her oxygen saturation had fallen from 80 per cent to 65 per cent and she had cool hands and feet.”
Septic shock
Coroner Dr Ciaran MacLoughlin, asked in particular about her lactate levels at that point. “At what level does lactate level indicate septic shock?”
He said a level greater than four was indicative and at 3.30pm on the afternoon of Wednesday 24th she already had a level of 8.8. “A level greater than four is septic shock. Really we like to have them lower than 1.5.”
“So an elevated level a of lactate should be diagnosed, the earlier the better?” asked the coroner.
“Yes - that’s very important,” said Dr Bates.
Going over her symptoms again at 9am on Thursday 25th, Dr MacLoughlin asked: “The prognosis at that time was very poor, it would be fair to say?”
“Yes that would be fair to say.”
Eugene Glesson, SC for Mr Halappanavar, said his client wished him to tell Dr Bates and his colleagues in the ICU: “To his dying day he will be grateful for the valiant efforts made by you and your colleagues to save his wife, Savita.”
Dr Mac Loughlin earlier called for a senior midwife, Sr Gilligan, who phoned Dr Katerine Astbury at 1.20pm on Wednesday, October 24th , to tell her Ms Halappanavar hads deteriorated markedly, to give evidence.
The coroner adjourned to see whether expert witnesses, including Dr Peter Boylan, former Master of the National Maternity Hospital, who were due to give evidence next week, may be available tomorrow.
