Staff at University Hospital Galway failed to provide Savita Halappanavar with “the most basic elements of 
patient care” and failed to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner, according to a new report.
The report, carried out by the Health Information and Quality Authority points to 13 “missed opportunities” that could have saved Ms Halappanvar’s life had they been acted upon.
Mrs Halappanavar died last October after a case of sepsis in pregnancy, and it was repeatedly claimed that her death was due to abortion being illegal in Ireland.
The case was reported around the world, and Ireland’s abortion law was blamed for her death by the vast majority of media commentators.
Earlier reports, including the coroner’s inquest into the death, found that “systems failures” were responsible.
Among the missed opportunities listed in the report are a failure to carry out the recommended four-hourly observations of her temperature, heart rate and blood pressure and a failure to follow up blood tests, the Irish Times reports.
“The consultant, NCHDs (non-consultant hospital doctors) and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time,” according to the report. “However, this did not happen.”
It says the most senior clinical decision maker involved in the provision of care to Ms Halappanavar at any given time should have been suitably clinically experienced and competent to interpret clinical findings and act accordingly. “Ultimate clinical accountability rested with the consultant obstetrician who was leading Savita Halappanavar’s care.”
It says the consultant obstetrician, NCHDs and midwives/nurses caring for Ms Halappanavar did not appear to act in a timely way in response to her clinical deterioration and the report is critical of a failure to act or escalate concerns to “an appropriately qualified clinician”.
In a statement, the Pro Life Campaign accused the Irish Times of linking the tragic death of Savita Halappanavar to Ireland’s abortion laws before the full facts of the case had emerged.
Dr Ruth Cullen of the Pro Life Campaign said it was “obscene” how the paper “linked this tragic case to abortion from the very start and refused to withhold judgment until the full facts emerged”.
“We now know from today’s HIQA report and earlier reports that this story was never really about abortion and that the key issues in the death of Ms Halappanavar were basic deficiencies in patient care and the catalogue of failures in monitoring and recognising the grave risk to her life caused by serious infection.