A frightening picture of failure

Pro-life advocates are vindicated in the ‘Savita report’, writes Breda O’Brien

Sometimes a picture really is worth a thousand words. There is a diagram in the HIQA Inquiry Report into Maternity Services in the light of Savita Halappanavar’s death, and it shows 13 missed opportunities. 

The picture painted is frightening. As HIQA’s Director of Regulation, Phelim Quinn, said: “The investigation findings reflect a failure in the provision of the most basic elements of patient care to Savita Halappanavar. They identified a failure to recognise that she was developing an infection and then a failure to act on the signs of her clinical deterioration in a timely and appropriate manner. The investigation also identified a number of missed opportunities to intervene in her care which, if they had been acted upon, may have resulted in a different outcome for Savita Halappanavar.”


This is what pro-life advocates have been saying all along. This story was editorialised from the very beginning, rather than reported.  If the headlines had said, ‘Woman dies of sepsis after miscarriage’, it would not have been picked up by news outlets all around the world, but it would have been more accurate.

Sadly, so serious did the problem of sepsis become in British maternity hospitals, that in 2007, the Royal College of Obstetricians and Gynaecologists (RCOG) issued two special guidelines on sepsis prevention in pregnancy and after.

In the one for pregnant women, it declares: “Symptoms of sepsis may be less distinctive than in the non-pregnant population and are not necessarily present in all cases; therefore, a high index of suspicion is necessary.”

In other words, be extremely vigilant when a pregnant woman is in your care.

Irish obstetricians are expected to adhere to RCOG guidelines. Although the strain of E coli ESBL that killed Savita is extraordinarily virulent, there is an internationally recognised way of ensuring vital signs are not missed. It is known as the Modified Obstetric Early Warning System, (MOEWS) and has been compared to a set of traffic lights.

Certain indicators change the traffic lights to amber, while others are an immediate red light, signalling the need for urgent action. The aim is to never get to the need for the red lights.

MOEWS has its limitations, not least if it is followed too slavishly, as nothing beats the experienced, vigilant eye. Malcolm Gladwell in his book, Blink, identifies a level of skill that is almost instinctive, because of constant honing. That level of expertise will spot an unwell patient almost before she knows it herself.

University Hospital Galway did not have in place the most advanced microbial guidelines (what the layperson would call an antibiotic regime.) 

It had not implemented MOEWS. The ward, St Monica’s, dealt with an extraordinary variety of patients, everything from miscarrying mothers to women undergoing investigation for infertility.


I have no doubt that the midwives were under pressure. Staffing levels in all our maternity hospitals are a problem. There should be no witch-hunt of medical personnel, but lessons should be learned.

The most shocking aspect is that lessons were not learned from Tania McCabe, who died in 2007 after giving birth to very premature twins, one of whom, Zach, sadly, had a life limiting condition. Her other son, Adam is alive and well, thank God.

Do you remember marches demanding abortion ‘rights’ after Ms McCabe’s death? That’s right, you don’t, because there were not any. Instead, you had a brave family dealing with grief by fundraising for incubators for premature babies.

So what do we have, a year after Savita? A damning report that says “only five of the 19 maternity hospitals/units were able to provide a detailed status update on the implementation of recommendations from the Tania McCabe report”.

Professor Emeritus John Bonnar is one of the most respected obstetricians in the country. He said from the beginning, that poor Savita should have been watched like a hawk, because it was very probable that she might be harbouring an infection, which might have even led to the miscarriage in the first place.

The law

Yet all we got, relentlessly, from other powerful voices, was that the law was at fault. Did the law cause a ‘general lack of provision of basic, fundamental care’?

We all know the answer to that. The law did no such thing. The Government knew that, because it heard it at the Oireachtas Hearings.

Supporting existing good practice by legislation would have been fine, but the current legislation instead blurs the distinction between the death of an unborn child as an unsought for consequence, and directly targeting the child.

It has also introduced a dangerous law regarding a ‘right’ to abortion in the case of suicidal ideation. We have taken the first, radical step away from protecting life. 

It is very sad, sadder still because the urgent demand to legislate came from a litany of failures that deprived Praveen Halappanavar of both his wife and child.