|Savita Halappanavar’s husband Praveen speaks to the
media last Friday after the inquest into his wife’s death concluded.
The inquest into the death of Savita Halappanavar did not blame anyone for her death. Despite all we have heard over the past two weeks, no one is to be held accountable.
Even the hospital is not to be blamed, despite the admission of the consultant (senior doctor) involved in Savita's care that her death was due to a "systems failure" in her treatment in hospital (mainly due to poor communication and mistakes). Instead the main finding of the inquest is that Savita died of "medical misadventure."
It's an antiquated term, like much of the law and the terminology relating to inquests. In plain man's language it's like saying that something was an accident, a happening for which no one is responsible. It even carries the suggestion of an element of bad luck.
Misadventure -- a sort of accident due to bad luck. It's an interesting legal term.
It's also a totally inadequate term to describe the appalling combination of Catholic-inspired law, medical incompetence, mistakes by hospital staff, inadequate record keeping, poor communication and failure to care that resulted in Savita's death.
But it would be a mistake to blame the coroner who conducted the hearings for the unsatisfactory nature of the main finding of the inquest.
An inquest in not a criminal court. It is confined by legislation to establishing the cause of a death. That is its sole function, and it is specifically excluded from finding anyone guilty or even of apportioning blame.
In this case there is general agreement that the coroner did an excellent job in making public for the first time the circumstances and the causes of Savita's death. It may not be the complete picture, given the limitations of a coroner's court and fact that one key witness did not give evidence.
But it has given us a great deal of detail about what happened, detail that has shocked the country and punched a large hole in the credibility of our claims about having one of the best maternity hospital systems in the world.
What emerged during the six days of the inquest over the past two weeks was really frightening. A tragedy of errors, Savita's care was a shameful sequence of failure to diagnose what was happening to her, of poor or inadequate treatment, of sloppy medical records and failure to read notes, of failure to communicate between staff, of delayed testing and so on.
Above all, it exposed the refusal of the hospital to allow her a termination until it was too late.
It started right at the beginning. She went to the hospital on the Sunday in pain, probably in the early stages of miscarriage, but this was not diagnosed and she was sent home again. In more severe pain, she returned a few hours later, was admitted and was found to be miscarrying.
It was established that her membranes had ruptured (leaving her open to infection) and that there was very little chance of the baby surviving (she was 17 weeks pregnant).
Still in pain and instinctively feeling that she was not well, on Monday and Tuesday she asked for a termination. Her consultant explained that the law prohibited a termination because there was still a fetal heartbeat present. A midwife explained that this was because "Ireland is a Catholic country," the remark that made news around the world.
There were failures to notice changes in her blood cell counts, indicating sepsis (blood poisoning). Incredibly, when she began to shiver violently (a clear indication of the onset of blood poisoning) she was given a paracetamol pain tablet and a blanket.
By the time she was diagnosed, on the Wednesday, the sepsis was already advanced. Her consultant, who had delayed a termination because she was awaiting the fetal heartbeat to stop and for the results of a blood test that had gone astray, finally agreed to intervene.
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