The HSE report on the death of Savita Halappanavar at University Hospital Galway last October complements the detailed information that emerged from her inquest in April. Much of the information is not new; however, the investigating team has combed through the issues forensically leading to some detailed recommendations designed to improve patient care.
It describes a key factor that caused Ms Halappanavar’s death as “inadequate assessment and monitoring that would have enabled the clinical team to recognise and respond to the signs that the patient’s condition was deteriorating due to infection associated with a failure to devise and follow a plan of care for this patient”.
In other words had four-hourly measurements of pulse, blood pressure, temperature and respiratory rate been carried out in accordance with guidelines to manage a pregnant woman whose waters have broken, then the clinical team would have reacted more promptly.
Warning system
If, in turn, these basic measurements had been fed into a modified early-warning score system, then a stepped management process would automatically have been triggered: when a certain score is reached, the midwife is obliged to contact a junior doctor; in turn a higher score means the specialist registrar must be asked to see the patient; and so on until the consultant is called and, if necessary, the patient transferred to a high-dependency environment.
Of course, we now know that an early warning system was not operating at the time in the ward where Savita was initially cared for; in compliance with one of the report’s recommendations the system has now been implemented in all hospitals in the Republic with a maternity unit.
"Failing to devise and follow a plan of care for this patient" is a fairly damning indictment of the healthcare professionals who looked after Ms Halappanavar. Essentially the investigation team is saying that communication within and between disciplines was inadequate. So even had the information gathering and processing been perfect, without an "action plan" such quality information about the patient's condition becomes redundant.
Patient management
The HSE is presently implementing a system to deal with this potential deficit in patient management. The"Isbar" tool is designed to ensure a minimum amount of appropriate information is transferred between doctors, nurses and others when they discuss individual patients. I stands for identification – who you are; S represents situation – why are you calling; B is for background – what is the relevant background; A for assessment – what you think is the problem; and R represents recommendation – what would you like the person you are speaking with to do?
In the Savita case, the report uses the example of junior doctor SHO2 recalling giving all her vital signs in a phone call with registrar O&G R3. However, the registrar did not recall SHO2 giving details of the patient’s pulse rate or blood pressure at this critical juncture.
The investigation team found that had a system such as Isbar been in place, the communication of vital information in this and other instances would have been more complete and in all likelihood expedited the patient’s management.
While the issue of abortion has largely dominated coverage of Ms Halappanavar’s case, it is the report’s recommendations on getting the basics of clinical care right that are likely to help save patients’ lives.