Review of governance structures at University Hospital Galway under way in wake of Savita’s death

A review of governance structures at University Hospital Galway is under way in the wake of the death of Savita Halappanavar in October 2012.

The review is one of many recommendations arising from separate investigations into her death by the HSE and the Health Information and Quality Authority.

A report on progress in implementing the recommendations has been released by the HSE to The Irish Times under freedom of information legislation.

Recommendation
One recommendation was that the Galway-Roscommon Hospital Group should "review its current governance structures and arrangements, including cross- committee membership, in order to ensure that these are in line with the principles of good governance".

The report says a review of governance structures took place on December 19th, 2013, and a follow-up meeting was scheduled for February 5th.

Ms Halappanavar died at University Hospital Galway on October 28th, 2012, having presented a week earlier with back pain. She was 17 weeks pregnant and was miscarrying. She asked several times for the pregnancy to be terminated. This was refused, however, as the foetal heartbeat was present.

Ms Halappanavar went on to deliver a female foetus, but was transferred straight to the hospital’s high-dependency unit and then to intensive care, where she died of septic shock.

Her death led to three inquiries, including a coroner’s inquest. Shortcomings in her care were identified, including that blood tests were not followed up; lactate samples were not tested; a lack of communication between staff about her deteriorating condition; the absence of an early-warning system; and lack of clarity about who was leading her care.

This report focuses on progress in implementing 15 local recommendations and 18 national priorities.

It says these are all being addressed, including that a new handover process for the hospital’s maternity unit is in place every morning; the “roles and responsibility for following up investigations has been clearly outlined”; and an early-warning score system is in place across the hospital.

Nationally, guidelines are being developed on such issues as the management of miscarriage in the first and second trimester; sepsis in pregnant women; the role of the consultant on call; and the delivery of training programmes for all maternity sites in obstetric emergencies.