THE CORONER IN the inquest into the death of Savita Halappanavar has summed up the evidence heard over the past two weeks and charged the jury, giving it a choice of two verdicts – a narrative verdict or a verdict of medical misadventure.
The inquest, one of the longest in Irish history, was a fact-finding mission into how the 31-year-old dentist died on 28 October 2012. She was admitted to Galway University Hospital on 21 October with severe back pain when she was 17 weeks pregnant.
Dr Ciarán McLoughlin told the jury that Dr Astbury admitted there were systemic failures in the checking of the patient’s vital signs during a period of her treatment over the next seven days. Another witness Dr Peter Boylan spoke of deficiencies in the patient’s medical management.
Before discharging the jury, the coroner told the six women and five men that if they found the facts heard from witnesses – about blood samples not being acted upon and the “inordinate delay” in reporting back to the ward, about the conflict of evidence between medical and nursing staff which may not have occurred if there were separate notes and the systemic failures noted by Dr Astbury – to be deficiencies, they they could return a verdict of medical misadventure. He added that this does not infer civil or criminal liability.
He described a systems failure as “one that could affect more people in the future unless rectified”.
Addressing the controversial issue of Ireland’s abortion legislation, Dr McLoughlin said, “It is not for the court to advise the Oireachtas but they may take cognisance of these proceedings.”
He described the Medical Council’s guidelines on abortion as “very brief” and in his first recommendation to the jury, he told them they could advise the council to lay out when exactly a termination can be carried out if there is a risk to the life of the mother.
He said doctors who practice medicine in good faith should not have to labour under the threat of sanctions as severe as prison or being erased from the medical register, which puts them on a “path of ignominy and shame”.
The coroner also gave the jury eight other recommendations which it can accept or reject. It also has the power to make its own recommendations. He said nursing and medical staff should keep separate notes on patients; treatment plans should be explained so they can be understood by patients and relatives; protocols for sepsis should be written by the microbiology department in each hospital nationally and communications between staff on call and those coming on duty should be improved by dedicating time to an official handover meeting.
In his final recommendation, Dr McLaughlin recommended that no medical notes be added to the files of a deceased patient.
Savita’s husband, Praveen Halappanavar, gave evidence on the first day of the proceedings and the 11-person jury has since heard from experts and hospital staff who treated the deceased. A total of 36 witnesses presented.
Earlier today, Dr McLoughlin heard submissions from Mr Halappanavar’s lawyers and a response from the hospital’s legal team.
On arriving to Galway County Hall, Mr Halappanavar told reporters today marks the couple’s fifth wedding anniversary. This fact was also noted by Mr Gleeson during his application.
The verdict is expected later today.
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