INDIAN dentist Savita Halappanavar who was refused a termination in an Irish hospital as she miscarried, died as a result of medical misadventure, a jury at her inquest has unanimously ruled.
Earlier today, the coroner had told the jury of six men and five women that they could return a verdict of medical misadventure or a narrative, and said a narrative verdict would simply find that Savita Halappanavar was 17 weeks pregnant when admitted to hospital with a pending miscarriage, that her membranes ruptured and she developed sepsis, severe sepsis and septic shock and died.
He told the jury they have an option of returning a verdict of misadventure if they find there were “system failures or deficiencies” in her medical care before she died.
Dr MacLoughlin warned that neither verdict could put blame on any person or persons.
He also gave the jury the option of making nine recommendations based on evidence heard during the inquest.
Dr MacLoughlin spoke to the jury for almost 20 minutes, his voice shaking as he spoke of Mrs Halappanavar’s days.
He outlined her treatment from the day she was admitted, the system failures that have been admitted by staff, and spoke of how Mrs Halappanavar “was in peril of her life” as she contracted sepsis.
“The life of this vibrant woman ebbed away,” he said.
The coroner promised Mr Halappanavar an open and transparent inquiry when it opened two weeks ago and said he had heard from 36 witnesses - family, friends and experts in their fields - about her treatment.
He gave the jury their options for a verdict and offered them nine recommendations they could consider.
“It is not for the court to recommend a change of the law but the Oireachtas (Irish Parliament) may take countenance of these procedures,” he said.
The recommendations are:
• The Medical Council should say exactly when a doctor can intervene to save the life of a mother, which will remove doubt or fear from the doctor and also reassure the public;
• Blood samples are properly followed up;
• Protocol in the management of sepsis and guidelines introduced for all medical personal;
• Proper communication between staff with dedicated handover set aside on change of shift;
• Protocol for dealing with sepsis to be written by microbiology departments;
• Modified early warning score charts be adopted by all staff;
• Early and effective communication with patients and their relatives when they are being cared for in hospital to ensure treatment plan is understood;
• Medical notes and nursing notes to be kept separately;
• No additions or amendments to be made to the medical notes of the dead person who is subject to an inquiry.