Main points: HSE report into death of Savita Halappanavar

Main points:

Care options
The hospital failed to offer all management options to Ms Halappanavar as she experienced inevitable miscarriage, even though the risk she faced increased from the time her membranes ruptured

Legal uncertainty
The interpretation of the law relating to lawful termination in Ireland - in particularly the lack of clear clinical guidelines and training - was a "material contributory factor" in not terminating the pregnancy earlier

Over-emphasis on foetal heartbeat
The report found an apparent over-emphasis on the need not to intervene until the foetal heartbeat stopped, and not enough emphasis on the need to focus on managing the risk of infection

Clinical guidelines
Hospital staff failure to adhere to clinical guidelines by for prompt and effective management of sepsis when it was diagnosed

Poor action over blood tests
There was a lack of clarity over who was responsible for following up and acting on blood cell results. As a result, blood tests taken after Ms Halappanavar's admission were never followed up.

Communications issues
There investigation team was concerned over the lack of procedures for effective communication. For example, one medic recalled giving Ms Halappanavar's vital signs, but a consultant did not recall this happening.

Inadequate assessment
Staff failed to properly monitor and assess Ms Halappanavar's condition, which would have allowed the clinical team to recognise and respond to the signs that her condition was deteriorating

Ultrasound failure
A medic said no ultrasound was carried out on Ms Halappanavar on the night of her admission because a scanning probe was broken and images from a portable scanner were not of good quality

No early warning system
The lack of an early warning score chart system contributed to the difficulty and delay in the diagnosis and management of Ms Halappanavar's condition. These charts are useful in assisting and focusing on potential dangers