Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar executive summary and recommendations

Hdl Handle:
http://hdl.handle.net/10147/303139
Title:
Investigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar executive summary and recommendations
Authors:
Health Information and Quality Authority (HIQA); Social Services Inspectorate (SSI)
Publisher:
Health Information and Quality Authority (HIQA), Social Services Inspectorate (SSI)
Issue Date:
7-Oct-2013
URI:
http://hdl.handle.net/10147/303139
Item Type:
Report
Language:
en
Description:
The Authority identified, through a review of Savita Halappanavar’s healthcare record, a number of missed opportunities which, had they been identified and acted upon, may have potentially changed the outcome of her care. For example, following the rupture of her membranes, four-hourly observations including temperature, heart rate, respiration and blood pressure did not appear to have been carried out at the required intervals. At the various stages when these observations were carried out, the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Savita Halappanavar did not appear to act in a timely way in response to the indications of her clinical deterioration. In summary, of the care provided there was a: n general lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in the case of Savita Halappanavar n failure to recognise that Savita Halappanavar was at risk of clinical deterioration n failure to act or escalate concerns to an appropriately qualified clinician when Savita Halappanavar was showing the signs of clinical deterioration. The consultant, non-consultant hospital doctors (NCHDs) and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time. However, this did not happen.The most senior clinical decision maker involved in the provision of care to Savita 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. In addition, the clinical governance arrangements within the Hospital failed to recognise that vital Hospital policies were not in use nor were arrangements in place to ensure the provision of basic patient care on St Monica’s Ward. These included guidelines relating to the observation of obstetric patients through the use of a maternal early warning score chart and the management of sepsis and pre-term pre-labour rupture of membranes. Furthermore, the healthcare medical record documentation of Savita Halappanavar’s care lacked detail in relation to her clinical status and the potential risk of clinical deterioration at identified times throughout her care pathway.
Keywords:
PATIENT SAFETY; MIDWIFE; MATERNITY SERVICE; PREGNANT WOMEN

Full metadata record

DC FieldValue Language
dc.contributor.authorHealth Information and Quality Authority (HIQA)en_GB
dc.contributor.authorSocial Services Inspectorate (SSI)en_GB
dc.date.accessioned2013-10-10T13:08:33Z-
dc.date.available2013-10-10T13:08:33Z-
dc.date.issued2013-10-07-
dc.identifier.urihttp://hdl.handle.net/10147/303139-
dc.descriptionThe Authority identified, through a review of Savita Halappanavar’s healthcare record, a number of missed opportunities which, had they been identified and acted upon, may have potentially changed the outcome of her care. For example, following the rupture of her membranes, four-hourly observations including temperature, heart rate, respiration and blood pressure did not appear to have been carried out at the required intervals. At the various stages when these observations were carried out, the consultant obstetrician, non-consultant hospital doctors (NCHDs) and midwives/nurses caring for Savita Halappanavar did not appear to act in a timely way in response to the indications of her clinical deterioration. In summary, of the care provided there was a: n general lack of provision of basic, fundamental care, for example, not following up on blood tests as identified in the case of Savita Halappanavar n failure to recognise that Savita Halappanavar was at risk of clinical deterioration n failure to act or escalate concerns to an appropriately qualified clinician when Savita Halappanavar was showing the signs of clinical deterioration. The consultant, non-consultant hospital doctors (NCHDs) and midwifery/nursing staff were responsible and accountable for ensuring that Savita Halappanavar received the right care at the right time. However, this did not happen.The most senior clinical decision maker involved in the provision of care to Savita 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. In addition, the clinical governance arrangements within the Hospital failed to recognise that vital Hospital policies were not in use nor were arrangements in place to ensure the provision of basic patient care on St Monica’s Ward. These included guidelines relating to the observation of obstetric patients through the use of a maternal early warning score chart and the management of sepsis and pre-term pre-labour rupture of membranes. Furthermore, the healthcare medical record documentation of Savita Halappanavar’s care lacked detail in relation to her clinical status and the potential risk of clinical deterioration at identified times throughout her care pathway.en_GB
dc.language.isoenen
dc.publisherHealth Information and Quality Authority (HIQA), Social Services Inspectorate (SSI)en_GB
dc.subjectPATIENT SAFETYen_GB
dc.subjectMIDWIFEen_GB
dc.subjectMATERNITY SERVICEen_GB
dc.subjectPREGNANT WOMENen_GB
dc.titleInvestigation into the safety, quality and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration, including those provided in University Hospital Galway, and as reflected in the care and treatment provided to Savita Halappanavar executive summary and recommendationsen_GB
dc.typeReporten
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