The final report into the death of Savita Halappanavar has found that there was a failure to provide basic elements of patient care, and that Savita's life could have been saved if missed opportunities had been acted upon.
The Health Information and Quality Authority (HIQA) report points to a total of 13 missed opportunities, that, had they been identified and acted upon, "could have resulted in a different outcome" for Ms Halappanavar.
Blood test results were not followed up, and a series of signs that indicated Mrs Halappanavar's deterioration were not recognised or acted on.
Nuala Lucas, a consultant obstetric anaesthetist who led the investigation team, said there "were a series of signs that could have been recognised as indications of Mrs Halappanavar's deterioration or as signs of the development of sepsis.
Significantly, she said that if those signs had been identified, Savita's life may have been saved: "there may have been a different outcome".
Staff failed to recognise that she had a potentially virulent infection which led to septic shock and to Ms Halappanavar's death.
The HIQA report said that following the rupture of Savita's membranes she should have been observed every four hours, and her temperature, heart rate, breathing and blood pressure checked. This did not happen.
Key findings included:
The hospital did not follow its own guidelines on early warning alerts for a patient who could be deteriorating.
It also ignored its own guidelines on sepsis and the early rupture of membranes in pregnancy.
Vitally important information about Savita's condition was not shared by doctors looking after her - including information of her deteriorating condition.
The report found there is no nationally agreed definition of maternal sepsis and inconsistent recording of it nationally.
Niamh Uí Bhriain of the Life Institute said that "the report made it very clear that the management of sepsis in pregnancy was always the issue here - and not abortion."
She said that the "shameful rush" by the media and by some politicians to exploit the tragedy to push for abortion was now fully revealed.
"The Irish Times led the world to believe that this was about abortion: when we now know it was about a failure to provide basic care," she said. "Our thoughts are with Praveen Halappanavar at this difficult time".
Savita Halappanavar died on October 28th, 2012 in Galway University Hospital. Her cause of death was documented as being as a result of septicaemia - which is blood poisoning caused by a bacteria: in this case a super-bug that had infected her blood stream. It was, the coroner was later told, the worst case of sepsis seen in 30 years.
Three weeks later the front-page headline of the Irish Times read: “Woman ‘denied termination’ dies in hospital”, linking this woman’s death to Ireland’s law on abortion, and to Catholicism and igniting an already heated debate on abortion in Ireland.
Ms Halappanavar's tragic death was used by legislators to overturn Ireland's pro-life laws and legalise abortion on suicide grounds.
Ms Uí Bhriain said that there should be a public inquiry into the conduct of the media in the case, and their role in misinforming the public.
"Mothers need to know they are safe in Irish maternity hospitals, but instead of focusing on inadequacies of care, the media has spent the past 12 months shrilly demanding abortion legislation," she said. "That's the kind of agenda-driven focus that actually puts women's lives in danger."
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