Death of Savita Halappanavar
|Date||28 October 2012|
|Location||University Hospital Galway, Galway, Ireland|
|Cause||Septicemia and multiple organ failure|
|First reporter||Kitty Holland and Paul Cullen, The Irish Times|
The death of Savita Halappanavar on 28 October 2012, at University Hospital Galway in Ireland, led to nationwide protests—which spilled over into India, Britain and many other countries—calling for a review of the abortion laws in Ireland. Halappanavar, a Hindu Lingayat of Indian origin, was suffering from a miscarriage when she was some 17 weeks pregnant, and she sought medical attention and treatment at University Hospital Galway. Her requests for an abortion were refused, with her being told on one occasion that "it was the law, that this is a Catholic country." During the next several days, Halappanavar was diagnosed with septicemia which led to multiple organ failure and her death.
However, events had spiralled into motion once the events became public. The news of Halappanavar's death spread rapidly through both traditional and social media outlets, with one of the original stories in The Irish Times on 14 November receiving over 700,000 hits by 17 November. Rallies and protests were held, calling for a change in the abortion laws in Ireland, which the protesters claimed led to Halappanavar's death. Indian diplomatic and consular officials requested an official inquiry into the events surrounding Halappanavar's death. The United Nations Special Rapporteur for physical and mental health also became involved, saying abortion should be legal if a pregnancy is adversely impacting a woman's health in a negative way.
Prior to the investigations Taoiseach Enda Kenny, has stated: "I don't think we should say anything about this until we are in possession of all the facts." The Health Service Executive (HSE) named Professor Sir Sabaratnam Arulkumaran to head a seven-member panel looking into the case. The panel will seek to uncover all the facts and "to identify any safety issues arising in this case".
- 1 Background
- 2 Halappanavar's death
- 3 Reaction
- 4 HSE inquiry
- 5 HIQA report
- 6 Aftermath
- 7 See also
- 8 Sources
- 9 External links
Under previous Irish law, according to the Offences against the Person Act 1861, as amended, an unlawful act of abortion is a criminal offence punishable by imprisonment. Following a ruling of the Supreme Court of Ireland in 1992—now known in Ireland as the X case—terminations are allowed under certain circumstances, where "a pregnant woman's life was at risk because of pregnancy, including the risk of suicide".
This has now been codified into law. Peter Boylan, of the Irish Institute of Obstetricians and Gynecologists, said: "The current situation is like a sword of Damocles hanging over us. If we do something with a good intention, but it turns out to be illegal, the consequences are extremely serious for medical practitioners."
Savita Halappanavar, a 31-year-old citizen of India, originally from Belgaum, in the Indian State of Karnataka, and who was working in Ireland as a dentist, died at University Hospital Galway. She was suffering from a miscarriage when she was some 17 weeks pregnant on 21 October. She repeatedly asked for an abortion, but it was claimed by the media that she was told that, because Ireland was a "Catholic country," she could not have one while the foetal heartbeat was still present, although it was non-viable. The foetal remains were removed several days later on 24 October. Savita Halappanavar suffered septicemia and organ failure and died a few days later on 28 October 2012.
Halappanavar's death led to protests at Galway, particularly from the local Indian expatriate community. The University Hospital is currently a subject of several investigations. Halappanavar had been one of the organisers of the annual Galway Diwali festival, which was cancelled in response to her death.
Reports about Halappanavar's death began spreading after the Tonight with Vincent Browne programme showed front-page stories by The Irish Times and the Irish Independent newspapers on 13 November 2012. The reports were further disseminated on Twitter, including by such journalists as Caitlin Moran and India Knight, and were covered by publications such as BBC News, the British edition of The Huffington Post, and The Guardian, The Daily Telegraph, Daily Mirror, The Independent and the Daily Mail newspapers.
On 14 November 2012, more than 2,000 people gathered to protest against Ireland's abortion laws outside Leinster House in Dublin, in Halappanavar's memory. In addition, a candle-light vigil was held in Cork in Halappanavar's memory.
There were calls upon the Taoiseach to secure an external enquiry into the circumstances surrounding Halappanavar's death. There are also calls for a change in the law, as the present legislation is an Act of the British Parliament of 1861—when Ireland was still part of the United Kingdom —which declares that it is unlawful to "procure a miscarriage". On 16 November, the Irish Health Service Executive established an independent inquiry into the circumstances surrounding Halappanavar's death.
On Saturday 17 November, the Garda Síochána (Ireland's national police) estimated that between ten and twelve thousand protesters marched from Parnell Square to Merrion Square to demand a change in the law, whilst other rallies were also held across Ireland and in many other countries abroad. On the other side of the issue, figures for the Pro-Life movement were as high as 50,000 persons who were rallying to keep the existing laws in place.
Medical terminations had previously been performed at the University Hospital when complications had arisen in pregnancy, as it is permitted by Irish law to save the life of the mother. In an opinion piece in the Daily Mail, Paul Bracchi speculated that an investigation would be carried out into why this did not occur in Halappanavar's case.
On Monday, 19 November, the Catholic Bishops of Ireland met in response to Halappanavar's death and released a statement that the Catholic Church believes in the "equal and inalienable right to life of a mother and her unborn child" and that the Church has never taught that the life of an unborn child takes precedence over the mother.
Eilis O'Hanlon stated that in its initial coverage, The Irish Times had "opted to present what had happened as a simple morality tale" and that "[t]he debate for the rest of the week was coloured entirely by The Irish Times's decision to reduce a complex personal tragedy, about which few facts were still known, to a rallying call." An analysis in The Irish Times on 17 November stated: "There is much we do not know about the medical care Savita Halappanavar received" and "even before the full facts are established Ms Halappanavar’s tragedy has generated much national and international coverage" in both traditional and social media of which some has been "careful and sympathetic" but "much ... has been intemperate, intolerant and politicised."
Response from the medical community
The staff of University Hospital, as well as members of Ireland's HSE Regional Health Forum, have stated that there is no "Catholic ethos" that is impacting treatment provided.
Dr Sam Coulter-Smith, a consultant in obstetrics and gynaecology and a university master in the Rotunda Hospital, one of the biggest maternity hospitals in Ireland, said: "This case probably does not have a lot to do with abortion laws." He added that it would be preferable to introduce legislation to bring in clarity, saying, "We really do need legislation in this area, otherwise we're going to be at risk of doctors working outside the law, and that's not appropriate."
Dr Rhona Mahony, the Master of the National Maternity Hospital, said: "[I]t is very disappointing that, 20 years after the 'X-Case', we don't have legislation" and that women "need to know that they are going to get the appropriate health care that they need" while doctors "need to know that they are also protected in their ability to do their job."
Microbiologist Dr James Clair stated that the "main problem is being missed" in the case, suggesting that the real issue may be that the septicemia was caused by extended-spectrum beta-lactamase positive gram negative bacteria (ESBL), which "are now spreading rapidly within the Irish population" and are resistant to many known antibiotic treatments.
Prior to publications of the reports, the Minister for Health, James Reilly, said that the public must not pre-judge the situation and further said that he was awaiting the results of the investigations, adding he had no evidence to suggest a so-called "Catholic ethos" at the University Hospital that prevented Halappanavar's life from being saved by a medical termination. He has also stated that an inquiry into Halappanavar's death must stand up to international scrutiny.
Brian Walsh, a Fine Gael TD for Galway West, said that Galway University Hospital had carried out terminations in recent years in accordance with the judgement by the Supreme Court in the X case and with the guidelines of the Irish Medical Council. He said that the University Hospital was not run or managed by any [Catholic] religious orders and did not have a so-called "Catholic ethos".
Fianna Fáil leader Micheál Martin said that Halappanavar's death was tragic and harrowing. Martin said that Ireland had always aimed for a low death rate during pregnancy but that this was "cold comfort" to Halappanavar and her surviving family and relatives. He said that an independent inquiry was needed, with experts from outside the country to establish the full circumstances. He also responded on Saturday 17 November saying that "legislating for the X case would not have stopped [the death of Savita Halappanavar]". On 18 December 2012, after a panel of experts submitted its report to the Parliament recommending, "the government legislate the issue in order to clarify what the current laws actually do and do not permit", Ireland’s Minister of Health, James Reilly, made a public statement marking an impending shift in Government policy, "..we will clarify in legislation and regulation what is available by way of treatment to a woman when a pregnancy gives rise to a threat to a woman’s life.."
Response of pro-choice organisations
Pro-choice campaigners state that Ireland's ban on abortion caused Halapannavar's death. Several rallies and vigils have been organised nationwide, calling for the government to legalise abortion based on Attorney General v. X. Irish Choice Network allegedly emailed members, calling for an emergency meeting to discuss how to proceed with this "major news story".
In response to critics accusing pro-choice activists of exploiting Halappanavar's death, Kate Smurthwaite responded in a column in the Huffington Post called "Yes, Savita Halappanavar's Death IS a Political Issue" in which she stated, "If I am ever a victim of an unjust legal discrepancy that infringes my human rights and leads to my untimely and unnecessary agonising death I want every man, woman and child on the streets immediately demanding that it never, ever be allowed to happen again."
Response of pro-life organisations
The Life Institute in Ireland has accused what it called "abortion campaigners" of exploiting Halappanavar's death to further the pro-choice agenda.
Michael Kelly of The Catholic World Report rejects claims that Ireland's abortion laws led to Halappanavar's death, writing that "medical experts and bioethicists have been quick to express their view that Ireland's ban on abortion had nothing to do with Mrs. Halappanavar’s death. They insist that guidelines from the Irish Medical Council are perfectly clear that pregnant women must be given all necessary medical treatment."
Father Shenan J. Boquet, president of Human Life International, said that there was no evidence to indicate that "a Catholic ethos" prevented responsible treatment of the mother, and called news reports that that was the case "demonizing the church's position on abortion". He described the debate resulting from the event as "activism masquerading as compassion and moral outrage."
In India, the Indian Minister for External Affairs, Salman Khurshid, summoned the Indian ambassador to Ireland, Debashish Chakravarti, to India for deliberations over the issue. Chakravarti later met Eamon Gilmore, Ireland's Tánaiste (deputy prime minister) and foreign minister, and promised to keep Halappanavar's husband up to date with the government's response.
Rajeev Chandrasekhar, an independent member of the Rajya Sabha (the upper house of the Parliament of India) said, "The death of Savita Halappanavar should be pursued by family and Govt. of India as a case of human rights violation and murder. Instead of simply protesting, cases should be filed against the Govt. of Ireland and its leadership at the International Court of justice and United Nations Commission for Human Rights UNHCR. This should move beyond protesting to where people are brought to account!"
In an editorial on 17 November 2012, The Times of India said, "There appears to be a tendency to view this issue in terms of India versus Ireland or the Catholic faith against other religions. To fall prey to such tendencies would be a serious mistake and a great disservice to the memory of Savita. ... Adding a nationalist or communal tone to the debate detracts from the merit of argument rather than enhancing it."
Amnesty International states that Halappanavar's death "illustrates [the] gap in Irish law" and asked the government of Ireland to change the law on abortion "in line with international human rights laws." The executive director of Amnesty International in Ireland, Colm O'Gorman, said that "successive Irish Governments have failed in their duty to provide necessary clarity on how this right is protected and vindicated, leaving women in Ireland in a very vulnerable position."
On 19 November 2012, the Health Service Executive (HSE) named Professor Sir Sabaratnam Arulkumaran to head a seven-member panel looking into the case. Arulkumaran is the head of obstetrics and gynaecology at St George's Hospital Medical School and is president-elect of the International Federation of Gynaecology and Obstetrics.
The panel sought to uncover all the facts and "to identify any safety issues arising in this case".
On 20 November 2012, three members of the panel were asked to step down when Praveen Halappanavar indicated that he would not cooperate with the panel due to their connections as consultants to University Hospital. Arulkumaran has requested a meeting with Mr. Halappanavar. On 21 November, the Irish Independent reported that Arulkumaran was being accused of being "pro-abortion" and promoting a "liberal" approach to abortion because of papers that he has published.
The Arulkumaran report was published on 13 June 2013. It identified three "Key Causal Factors" for the death: inadequate assessment and monitoring; failure to offer all management options to a patient; and non adherence to clinical guidelines related to the prompt and effective management of sepsis. It made six recommendations for improvements in patient care in such situations. All six recommendations call for improvements in healthcare guideline, training and practices, and one recommendation called for legislative changes if necessary to allow for expediting delivery for clinical purposes. Additionally, it made three recommendations to address incidental factors.
Key causal factors
The report indicates the first key causal factor was inadequate assessment and monitoring. This would have allowed medical staff to recognise and respond to indicators that the infection was causing a deterioration in Savita's condition. Additionally, staff failed to devise a plan of care recognising that: (1). Infection was the most likely cause of the patient's miscarriage, and, (2.) With increase in time following admission, and the rupture of the patient's membranes, the risk of infection and sepsis increases.
The panel identified the hospital's failure to offer all management options to a patient was a second key causal factor. The panel points out that the patient was "experiencing inevitable miscarriage of an early second trimester pregnancy where the risk to the mother increased with time from the time that membranes were ruptured."
The panel found that hospital staff failed to adhere to clinical guidelines which relate to severe sepsis and septic shock. These relate to timely and effective management of sepsis when it is diagnosed.
Recommendations of the Panel
- Prompt introduction of a Maternity Early Warning Scoring Systems Chart for patients with pregnancy complications in gynaecology wards. This should be followed by a compliance audit. The chart should indicate a monitoring coupled with an escalating nursing, medical and multidisciplinary response.
- Introduction of mandatory induction and education on early recognition, monitoring and management of infection and sepsis. This includes severe sepsis and septic shock.
- Development and implementation of national guidelines relating to infection and pregnancy, in addition to multidisciplinary educational programmes to improve care in such cases. In particular, there needs to be audited compliance with guidelines on management of infection, sepsis, and suspected sepsis in cases of inevitable miscarriage of an early second trimester pregnancy. This includes when there is a prolonged rupture of membranes, and increasing time from this point increases the risk to the mother.
- Compliance with guidelines on the management of early second trimester inevitable miscarriage. This should recognise possible rapid patient deterioration, possibly within a few hours, from sepsis to severe sepsis to septic shock. It should also recognise the high mortality rate, of up to 60 percent, associated with this. These guidelines should include the same emphases as those for infection and pregnancy listed in recommendation 3. The panel recommended such guidelines should include guidelines relating to expediting delivery for clinical reasons, including "medical and surgical termination" based on the expertise available and legal feasibility.
- The panel recommended improved communication practices between all relevant staff, and improvements in handover of acutely ill patients. Additionally, definitive tools for clearly communicating information relating to the deterioration of a woman's condition, consultation and/or handover to a higher level of care, according to ‘Improving patient handover – RCOG Good Practice No 12’ (Dec 2010).
- Compliance of guidelines on the consultants' responsibilities, according to the Royal
College of Obstetricians and Gynaecologists, “Responsibility of the consultant on call” (RCOG Good Practice No. 8 - March 2009). These indicate the need to involve senior medical staff due to difficulty coping with case load, or to consult on suspected serious cases. Midwives and nurses should be able to obtain help from senior nurse midwifery managers or the director of nursing on duty, and need to be able to contact the consultant if needed.
The Health Information and Quality Authority (HIQA) published a report into the incident on 9 October 2013. It found "a failure in the provision of the most basic elements of patient care to Savita Halappanavar", noting 13 "missed opportunities to intervene".
Partly in response to the death of Savita Halappanavar, the Irish government introduced the Protection of Life During Pregnancy Act 2013. Having passed both Houses of the Oireachtas in July 2013, it was signed into law on 30 July by Michael D. Higgins, the President of Ireland.
On 20 September 2013 Praveen Halappanavar's solicitor served legal proceedings against Galway University Hospital and separately against Dr Katherine Astbury. The proceedings claim that Savita's constitutional right to life had been breached and allege 30 issues of medical negligence.
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