Garda Sergeant Tania McCabe died in Our Lady of Lourdes Hospital, Drogheda, as a result of sepsis, on the 9th March 2007. Augustus Cullen Law acted on behalf of her husband and family in the subsequent legal proceedings. The Health Service Executive conducted an inquiry into the circumstances of her death, and produced a final report on the 27th March 2008. Two primary care management deficiencies were identified in failing to make a working diagnosis of ruptured membranes during Tania’s first admission to the hospital, and in failing to recognise/diagnose septic shock following her second admission and caesarean section. A total of 27 recommendations were made by the Health Service Executive in this report to increase the level of Obstetric care and to ensure that such a tragic occurrence did not repeat itself.
Following the death of Savita Halappanavar in University Hospital Galway on the 28th October 2012, a 31 year old woman pregnant with her first child, the Health Information and Quality Authority (HIQA) undertook an investigation into her care and the safety, quality, and standards of services provided by the Health Service Executive to patients, including pregnant women, at risk of clinical deterioration. The findings of this investigation were reported on the 7th October 2013 and have generated serious concern amongst the public. In making a number of damning findings in relation to the standard of care received by Mrs. Halappanavar, and the maternity services generally in this country, the Authority found a “disturbing resemblance” between this case and that of Tania McCabe. Mrs. Halappanavar’s death had also been caused by sepsis, with the report finding that a number of opportunities were missed which, had they been identified and acted upon, could potentially have altered the outcome. Of further grave concern was that as part of the investigation, only five of the nineteen maternity hospital/units in this country were able to provide a detailed status update on the implementation of recommendations from the Tania McCabe Report.
The following resultant indictment of our healthcare system from the HIQA report would indicate that unless significant reform is implemented with efficiency, further tragedies are inevitable;
“The lack of a nationally coordinated approach to the implementation of the recommendations of the HSE inquiry into the death of Tania McCabe, the lack of local governance arrangements to ensure that recommendations as applicable to their particular service are implemented, and the ambiguity regarding who has the overall ownership of and responsibility for implementing the National Clinical Care Programmes again raises a fundamental and worrying deficit in our health system”.
HIQA have made a total of 34 recommendations in the report.
You may obtain a copy of this report from the HIQA website.
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11 October 2013