Savita verdict – medical misadventure

SavitaPicVigil_large

Before going any further, we should all remember Savita’s husband Parveen Halappanavar in our thoughts and prayers. Today, the date that the inquest returned its verdict of medical misadventure following the death of his wife, they should have been celebrating their fifth wedding anniversary together with their newborn baby girl due to be be named Prasa. May they rest in peace.

There are already many disingenuous headlines in the press, stating that the inquest has ruled medical mismanagement, following the denial of an abortion to Savita, as if the two events are linked.

First of all, Savita was not denied an abortion, rather a termination of pregnancy. Though it may seem semantic, this is an important distinction. Though medically they both refer to the same end result, the term abortion is widely understood in the context of a woman who does not wish to have a baby. With women such as Savita, a termination of pregnancy is the more correct phrase, because the pregnancy and baby were accepted and welcomed. Savita wished for her pregnancy to be terminated swiftly when it became clear that she was miscarrying. She didn’t want to abort her unborn child, she wanted her miscarriage to be brought to a quick conclusion.

Savita’s request for her pregnancy to be terminated must be seen in the context of her miscarriage. The explanation given at the inquest, that this was not carried out because of the law, is an unsatisfactory one. The implication being that though there was a good medical reason to terminate the pregnancy, the law disallowed this.

Dr Katherine Astbury testified that on the Monday and the Tuesday, Savita did not appear to be unwell, though she was emotionally distressed. In these circumstances, Dr Astbury is quite correct, Irish law would not allow for a termination to take place, because there appeared to be no risk to Savita’s life. This is actually fairly reasonable. Poor prognosis for the foetus would not allow for a termination, because Ireland rightly places equal value on all life, born and unborn alike. That someone has a poor prognosis is not grounds to kill them. Patients who are given a diagnosis of a terminal or incurable disease are not then killed because the outlook looks bleak and neither are the elderly, much as people might agitate for euthanasia. Whilst there is life, there is always hope and when we take into account the fact that Savita’s pregnancy was a wanted one, so long as a life is not deemed to be at risk, then it is not morally acceptable to kill an unborn baby on the grounds that he or she is as likely going to die soon anyway.

The request to terminate the pregnancy from Savita, should not have determined what was in her best medical interests. All other things being equal, normal medical protocols dictate a conservative management (i.e. wait and see) approach. On a personal note, I can well imagine her distress and her physical pain. I was readmitted into hospital a week after my eldest child was born, suffering from retained infected placenta. When I apologised to the registrar in A&E for crying because I was in so much pain, his response was ‘madam, you have a uterine infection, it is going to hurt a lot’. In my case, despite my entreaties, they didn’t take me in for surgery for 4 days (it was Easter bank holiday weekend) preferring instead to administer IV antibiotics to cure the infection first and to see if the product would pass. Nine years on, I can still remember the pain vividly, but at least I was given the correct antibiotic treatment, though my desire to have a D&C and be back home was ignored. I can’t begin to imagine what Savita went through, especially when she had the ultrasound and could hear the heartbeat of her baby, whom she knew was shortly to die. It must have been awful for her and her husband, let’s not forget that.

But this question of abortion or termination is nonetheless the source of much misinformation. Speaking at the inquest Dr Astbury stated that had she known about Savita’s blood results on Monday or Tuesday, then she would have taken a different decision and terminated Savita’s pregnancy forthwith. Which begs the obvious question, why didn’t she? We know from the inquest that the blood test results taken from Savita at 6.33pm on the Sunday evening were immediately processed and were available on the hospital’s computer system at 6.37pm. They were not accessed until 5.24pm the next day, by an unidentified member of staff and Dr Astbury herself did not look at them until 11.24pm on the Wednesday morning, by which time Savita’s condition had severely deteriorated.

It is this delay that proved fatal for Savita. If a termination had been required, then Irish law allowed for this, the medical guidelines state that delivery of an unviable foetus may be expedited where there is real and substantial risk to the life of the woman. Sepsis would count as such a risk. Savita’s bloodcount was 16.9 (normal range 4.3 – 10.8) which should have rang alarm bells. She was definitely exhibiting signs of an infection which merited urgent further investigation which would have thrown up the presence of E.Coli. Real and substantial risk, are often confused with immediate. A woman does not have be in her death throes or dying for a real and substantial risk to be identified, simply that if a termination is not performed, there is a real and substantial risk that she will die.

With hindsight, this perhaps was the case with Savita, as she was at risk of chorioamnionitis (inflammation of the foetal membranes), once the membranes had broken on Sunday. Once this has happened there is a 30 – 40% risk of infection, which is why she was prescribed general oral antibiotics on the Monday evening. Had Dr Astbury thought Savita was at risk of this, or was exhibiting signs, then why were no further diagnostic tests peformed, in this case an amniocentesis would have confirmed whether or not chorioamnionitis was present. Regular monitoring to identify trends in the white blood cells count is also crucial.

What has confused the issue further is that Dr Peter Boylan, a doctor with a publicly stated position opposing abortion restrictions, testified as an expert witness stating that had Savita been allowed a termination earlier, it would have saved her life. It’s very difficult to know that with any certainty without recourse to a time machine. In any event the post mortem showed that it was the E.Coli bacteria that led to septic shock. The baby was not poisoning Savita’s bloodstream, though chorioamnionitis if diagnosed, requires delivery. If the baby had died then the placenta needed to be removed in order to halt the rapid of spread of infection spread via its dead blood cells. Bacterial chorio-amnionitis is exceedingly rare.

What we do know though, is that in 40 years there have been 5 cases of septic abortions, no patients have died and Savita’s case was very rare. Every year in Ireland there are sadly 14,000 miscarriages, many of them carrying an infection risk, and no maternal deaths on record where the obstetrician felt that the law was inhibiting them. Dr Sam Coulter Smith, master of the Rotunda Hospital in Dublin, says that he has terminated a pregnancy in four instances where women had been diagnosed with sepsis and in all of them the baby did not survive. It’s difficult to see then, how Irish law can be said to be putting women at risk.

The failure of Dr Astbury to discuss abortion outside of legal terms is what has proved troubling in this case. A surgical abortion would have carried with it real risks of further infection which could have proved fatal, and had Savita been given the drug misoprostel to induce delivery, this would not necessarily have made delivery any swifter or negated the need for surgical intervention. Faced with a fully dilated cervix and ruptured membranes, the medics could thought that delivery was imminent and there was therefore no need for further medical intervention at this point. They were therefore wholly wrong not to discuss this in medical terms with Savita and her her husband. Anyone would be cross if their request for a certain type of medical treatment was refused purely on legal grounds.

What is important is that today’s inquest ruled that there was medical mismanagement in the death of Savita Halappanavar. The jury had the option to deliver an a narrative verdict which would not have attributed a cause. Despite the verdict which implies failures in medical care, the judge, Dr McLoughlin, has thrown further confusion into the mix by stating the verdict did not mean that deficiencies or systems failures in University Hospital Galway contributed to Ms Halappanavar’s death; these were just findings in relation to the management of her care.

That seems to imply that there was nothing wrong with the general systems in place at University Hospital Galway, simply that the management of Savita’s individual care was unsatisfactory as we can see. One cannot help but wonder whether or not this is about offloading any legal liability that the hospital may incur in terms of compensation that might be due? After all, it was a galloping sepsis that killed Savita, stemming from the E.coli, ESBL bacteria that entered her bloodstream from the urinary tract and one that is antibiotic resistant. No-one can say with any certainty whether, even had the care been perfect, she would have survived this. Perhaps that is what the coroner is trying to convey, medical misadventure was a factor in relation to her care, but not necessarily in her death. It’s no wonder Parveen is still in the dark.

What urgently needs to be addressed is the factors behind the poor care. Did the law really make Dr Astbury too afraid to check blood results, which needed further analysis or carry out further diagnostic tests? Was the law behind the lack of regular observations, the lack of communication and the failure to realise that paracetamol administered as a painkiller could mask other symptoms? Did the law cause staff to forget that infection requires a low burden of proof? Or was it the effects of austerity measures on an already overstretched hospital struggling with lack of resources? What caused the glaring omissions and can any law be expected to cover every single permutation that might arise in the management of pregnancy or childbirth, or is this simply that medical guidelines need to be more precise and explicit?

Here is the list of the coroner’s recommendations which the jury all unanimously and strongly endorsed

* 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 to 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 the subject of an inquiry.

Savita’s request for a termination to have been accepted and acted upon, simply by dint of her wishes. would have required Ireland to have legislation which is much more liberal than even that in the UK, which in practice, allows abortion on demand.
It’s no wonder that the clamours for a repeal of the Eight Amendment of the Irish Constitution, (which defends the right to life of the unborn) have already started. None of which addresses the reasons behind the catastrophic failures in care.
Savita’s treatment timeline can be accessed here.

Postscript

One thing that should be emphasised is how rare it is to have a miscarriage at 17 weeks. 0.5% of single pregnancies in women with no history of recurrent miscarriages end in spontaneous second trimester foetal loss. Sepsis is still thankfully rare. Whilst it should be on the radar as a possibility, most maternity staff will not be panicking about the possibility of sepsis when a pregnant woman presents with a UTI. In the incidence of a UTI, blood samples are tested and antibiotics administered. A normal reaction to a UTI would not be to terminate the pregnancy as a precautionary measure. UTIs are serious if left untreated but no medical protocols would consider them as a real and substantial risk to life. Even with a suspected UTI there was no reason (in the absence of blood results) for medical staff to believe that Savita was dying.

I would be seriously concerned if any medic proposed termination of pregnancy as being necessary as a precautionary measure, unless it was in the most serious and grave of circumstances. Nowhere in NICE guidelines is termination mentioned as a treatment for a bacterial infection. Savita’s death should not prompt pregnant women diagnosed with a UTI to seek abortion and neither should they worry about contracting sepsis. One thing that should be remembered is the importance of scrupulous personal hygiene in terms of preventing the spread of bacteria such as E.coli.

Savita: Some more facts (For the hard of understanding)

There’s a fabulous phrase from Blackadder goes Forth, that would make for a very witty inscription on a tombstone and which I employ on frequent occasions when discussing pro-abortion advocates. Uttered by General Melchett (Stephen Fry before he manifested the symptoms of irrepressible smugness) whilst discussing the progress of the Great War, he tragically and comically sums up the attitude of those directing the war, thus:

If all else fails, a total Pig-Headed unwillingness to look facts in the face will see us through

I’m thinking in particular of the continued propagation of the idea that Catholic dogma played its part in the death of Savita Halappanavar, and the insistence that a timely abortion would have saved her life.

I’m going to spell this out very simply for the terminally hard of understanding.

Sunday 21st October 2012.

Savita was admitted to Galway University Hospital. She was suffering from backache and during the day had experienced some distressing blood and fluid loss. The hospital took bloods and examined her. The blood results that would have indicated that she had an infection were never followed up on, and Savita did not manifest obvious signs of infection. Sepsis is a deadly disease with a rapid progression which medical staff need to be hyper-vigilant about when dealing with pregnant women. Its symptoms can easily be masked by other symptoms in pregnancy, such as backache, raised temperature and generally feeling unwell. Savita had a history of back problems and had herself misdiagnosed her pain earlier in the day.

Savita would appear to have been suffering from a Urinary Tract Infection, (UTI) which are very common in pregnancy, need antibiotics to treat them, but are not necessarily life threatening. Let’s add into the mix that University College Hospital Galway, was over-stretched in terms of staffing and resources, this report in 2011 names it as the worst performing hospital in Ireland for the second consecutive month with calls for the Health Minister to intervene. The hospital seems to have been suffering from chronic shortages, which is something we should bear in mind before pointing the finger.

There is no reason at this point, to believe that Savita needed an abortion, let alone that her life might be at risk.

Upon examination it appears that Savita’s membranes are bulging and her cervix can’t be felt, meaning that a miscarriage is sadly imminent. There is no reason to believe that she is at risk of infection or that she needs an abortion. Later on, in the early hours of Monday morning, her membranes rupture. Again, there is no need to think that she may need unnecessary surgery, this seems like a regular miscarriage.

Monday 22nd October 2012

By 10pm on that evening, Savita’s waters had been ruptured for a full 22 hours. She was on antibiotics every six hours. It’s not clear when these were started, it should however have been from the moment the membranes ruptured and ideally based on the results of the blood culture taken on Sunday evening.

Tuesday 23 october 2012

At 8.20 am Savita is seen by Dr Astbury who informed her that ‘that the legal position in Ireland did not permit me to terminate the pregnancy in her case at that time.’ Savita is, at that point very distressed and requesting an abortion to put an end to her ordeal. No-one can blame her. She knows that she is miscarrying her baby and wants the whole thing to be over.

My take on this, is that Dr Astbury obviously sympathises. I think that she doesn’t want to take personal responsibility, or appear harsh and uncaring, nor does she want to cast the hospital in a bad light, there is no medical reason, or so it would seem, for an abortion, this isn’t life or death, they probably didn’t have a theatre or staff available at short notice and so she fell back on the letter of the law as an explanation. It’s fair to say that the law would not allow for an abortion in these circumstances, the foetal heartbeat is present, the patient seems comfortable and stable and no doubt many of the staff would have felt uncomfortable, given that this was not medically necessary, but it seems that there was no discussion as to why the hospital were taking the conservative management approach, one that would be taken in hospitals around the world. Hospitals do not deliver pregnant women the moment their membranes rupture, they can very often be sent home to get some rest in comfort, before being readmitted within the next 48 hours, depending on protocols and individual circumstances. It seems very remiss that Dr Astbury explains this in such a perfunctory and legalistic way. Surely Savita was owed more of an explanation?

If there was a clinical need for an abortion, why did Dr Asbury not consult with any of her colleagues? In any event, Savita was described as being “upset, but not unwell”.

Later on Dr Astbury testified that had she had access to Savita’s blood results earlier, then she would have taken theraputic intervention, i.e, an abortion, earlier. So how does this delay in terms of diagnosis and identifying the infection, equate with being the fault of Catholicism or uncertainty surrounding the legal situation?

But what does not make sense, is that if an infection is present or suspected, it is a contraindication for surgery – why invade a sterile uterus with instruments and risk flooding the body with further infection? Conservative management is always the default option in the treatment of miscarriages.

Wednesday 24 October 2012

This is the day that things begin to unravel for poor Savita. At 7am her pulse is 160 per minute (normal resting heart rate is usually between 60 and 80). Her blood pressure is 100/60 mm (normal is 120/80). Her temperature is 39.6 and in addition foul smelling discharge is present, suggesting infection. The doctor on duty concurs she is suffering from probable sepsis.

An hour and half later, 8.25 am, Dr Astbury and team see Savita on their ward rounds. Swabs are taken to determine what exact infection is present. According to the Irish Times, Dr Astbury testifies thus:

At this point her temperature had come down to 37.9 degrees and her pulse to 144bpm. She said she discussed with Ms Halappanavar the concern that she had inflamed foetal membranes due to infection.

“I also informed Ms Halappanavar that if we did not identify another source of infection or if she did not continue to improve we might have no option but to consider a termination regardless of the foetal heart.”

Mr Halappanavar has said he had no knowledge this discussion had taken place. In his statement he said he was at the hospital with his wife throughout Wednesday.

Subsequent to this, Savita deteriorates further, Dr Astbury consults with a colleague who agrees that delivery is medically necessary, a scan confirms that the baby has died, she is taken into theatre where she delivers, is subsequently transferred to HDU and then ICU and dies following further subsequent deterioration just after midnight on Sunday 28 October 2012.

Savita’s husband has no recollection of the conversation that a termination might be needed regardless of the presence of a foetal heartbeat.

Let’s leave aside the comments from the midwife, who was discussing abortions in a cultural context, Ireland’s Catholicism in relation to India’s Hinduism, in response to Savita’s request for an abortion. These obviously do not dictate care. Also Savita’s request for abortion should not be considered a factor. Patients’ wishes, whilst often taken into account, do not dictate what is best medical practice, as I learnt when I was refused the option of being able to deliver my youngest baby naturally. The doctors understood, they sympathised, they could see I was distressed and terrified and they did what they could to help me be comfortable, but ultimately they would not agree to the course of action that I requested, because it was deemed to be unsafe, and interestingly more unsafe for the baby than for me. I could not force them to act against my best medical interests.

Why would an abortion be required if the Dr could not find the source of the infection? It is clear that the baby could not have been the source of the infection. This is biologically impossible. A baby would not suddenly become infected and pass this onto the mother. The baby is in a sterile environment, even after the membranes have ruptured. The inflamed foetal membranes referred to, or to give it the correct medical term, chorioamnionitis, had not been identified. If this was the concern, which would require delivery, why wasn’t this possibility examined for sooner? It all seems like amateur guesswork. Finding the source of the infection, and treating the infection is a wholly different issue as to why the baby would need to be delivered. Plus we know that Savita presented with infection at the hospital, prior to the rupture of the membranes.

And here’s the absolute crunch. Four key failures. The blood test results performed on Savita on the Sunday evening admission, were ready at 6.37pm that evening, but not read until 5.25pm the next day. They were not then accessed again until after sepsis had been diagnosed and Savita’s condition was rapidly deteriorating, two days later. When Savita started shivering at 4.15am on the Wednesday morning, the first obvious signs that sepsis was raging through her body, her vital signs should have been checked. They were not. The blood culture sample taken from Savita at 8:29 am on Wednesday 24th October was processed onto the computer system by microbiology at 9.54 am but not reviewed by Dr Astbury until 11:20am. The lab also reported that the 2nd key sepsis test should have been performed on the ward, it was not. This a lactate serum test which could have definitively confirmed the presence of sepsis. The sample was taken at 6am on the Wednesday morning and stored in an inappropriate bottle before being sent to the lab who could not process it. The lab would not, in any event have carried out this test which should have been performed at a point of care unit on the ward.

The antibiotic treatment administered to Savita between 7am and 1pm was ineffective as it was erythromycin, a variant that is resistant to E-coli, the infection that pathology determined killed her. Broader spectrum antibiotics would have been a better choice.

The indications that Savita had sepsis were subtle and overlooked, by staff who were not deliberately negligent, but who were overstretched and under-resourced.

Catholics and pro-lifers have been writing today of the horrors of Kermit Gosnell. Pro-choicers have been calling his case an exception from which no broader conclusions can be drawn. Why then, in the case of Savita Halappanavar, and in the face of all evidence to the contrary in this one-off extraordinary case, under which Irish law allowed for an abortion, are they claiming that this is evidence that the law is causing women to die in droves?

Savita died from an E.coli infection, which the likelihood is, entered her urinary tract and bloodstream, causing her to miscarry. It was this bacteria that killed her and prompt identification of it, along with the correct antibiotics that could have saved her life. Aborting her baby would have made no difference to the progress of the disease and would have risked further infection and hastened death.

As well as holding the hospital to account, Parveen should be asking questions of the pro-choicers who have chosen to cynically exploit this tragedy for their own ends. The baby did not kill Savita, the E.Coli did.