Expert: Dying woman should have got Irish abortion

DUBLIN  — A miscarrying woman who died in an Irish hospital should have had her blood poisoning detected much sooner and been offered an abortion to improve her odds of survival, an experts' report concluded Thursday in a case that is forcing Ireland to modernize its abortion laws.

The 108-page report into the October death of Savita Halappanavar documented what the lead investigator described as "a cascade of mistakes" overshadowed by officials' refusal to remove the fetus until its heart stopped beating.

That took four days. By then, the report found, the woman's ill-diagnosed sepsis from a ruptured uterus already had reached lethal levels.

"If it was my case, I would have terminated the pregnancy," Dr. Sabaratnam Arulkumaran, a London professor of obstetrics and gynecology who led the seven-month probe, said. The five investigators found that a chain of doctors and nurses all failed to take proactive steps to identify and halt the spread of infection throughout her body.

The report found that when Halappanavar, a 31-year-old Indian dentist living in the western city of Galway, was hospitalized for back pain 17 weeks into her pregnancy, doctors identified she was miscarrying and the fetus could not survive.

But they consistently missed evidence for days pointing to an existing case of sepsis, or blood poisoning, as the cause. Blood test results were left uninspected and successive shifts failed to read earlier medical notes as vital signs worsened.

The report found that doctors placed too much emphasis on measuring the fetus' heartbeat and too little on investigating why Halappanavar's white blood-cell count was jumping, her blood pressure was falling and her heart rate and temperature were rising. All were signs of growing internal infection linked to a rupture in her uterus that a night-shift doctor identified in notes, but a day-shift doctor failed to read.

Arulkumaran said Ireland's doctors and constitutional lawyers must draft regulations that specify when an abortion can be performed on a pregnant woman suffering sepsis, because such cases can surge to lethal levels within hours.

He said some Irish doctors' wait-and-see approach, fearful of violating Ireland's constitutional ban on abortion, presented an unjustifiable courting of danger to the patient.

"When sepsis sets in, it is difficult to say who is going to live and who is going to die. We are just guessing here," he said, describing the death rate from severe sepsis as 40 percent and septic shock as 60 percent. He said if Halappanavar had received an abortion and aggressive doses of antibiotics early into her hospitalization, "the risk would be much less."

She delivered a dead fetus four days into her hospitalization, and fell into a coma and died of massive organ failure four days later.

The findings came hours after Ireland's government published a bill to create new rules on when doctors can perform abortions to save the life of a woman.

Six previous governments had refused to draft such a bill in support of a 1992 Supreme Court judgment that declared such abortions should be legal, given that the constitution — despite its supposed blanket ban on abortion — also guarantees to protect the woman's right to life.

Most controversially, the Supreme Court said abortion should be legal even when doctors deem one necessary to stop a woman from killing herself.

Anti-abortion activists argue that permitting a suicide threat as legal grounds would be open to abuse and encourage wider abortion access.

"The suicide ground will lead to abortion on request, and that will be very destructive of unborn children's lives and it's deeply unjust," Irish Sen. Ronan Mullen, a Catholic conservative, said.

Previous governments insisted they didn't need to pass any law in support of the court judgment, and instead twice tried to roll back its suicide provision in national referendums that voters rejected in 1992 and 2002. A 2011 European Court of Human Rights ruled that Ireland's inaction was jeopardizing women's health by forcing seriously ill women to travel overseas for abortions.

The legal limbo also has left Irish maternity hospitals and obstetricians to guess when they could perform an abortion to save a woman's life without facing the risk of a murder charge. Scores of such terminations have occurred annually in total secrecy for the past two decades, with the number of deaths connected to delayed treatment unknown. Halappanavar's case became public only because her widower spoke out, denouncing the imposition of Catholic teaching on a Hindu.

When presenting the Protection of Life During Pregnancy Bill, Prime Minister Enda Kenny declared in parliament that he "happens to be a Catholic" but could not govern as a Catholic prime minister. He wants the bill passed by July and is threatening to expel lawmakers from his party who oppose him.

Kenny's statement, during which he described receiving letters written in blood from anti-abortion activists, is being seen as a watershed moment in church-state relations in predominantly Catholic Ireland, where past generations of leaders showed public deference to church authority and handed substantial control of schools, hospitals and social services to Catholic orders.

The bill would permit abortions for women threatening suicide only if three doctors, including two psychiatrists, ruled that the woman's threat was severe. Abortions for non-emergency cases involving a threat to life would require support from two doctors.

Many lawmakers and doctors say Irish women will sidestep these Irish hurdles and keep traveling to neighboring England for abortions, where the practice was legalized in 1967. More than 4,000 Irish women receive abortions there annually.

"Unfortunately I don't think the provisions on suicide will encourage any woman to go through that system in Ireland," lawmaker Thomas Pringle said.

An opinion poll published Thursday in The Irish Times indicated overwhelming public support for the bill, with strong majorities wishing the bill extended abortion rights further.

The poll found 89 percent want abortions to be granted in cases where a woman's life is endangered from medical complications caused by pregnancy.

About 83 percent also wanted abortion legalized in cases where the fetus couldn't survive at birth, 81 percent for cases of pregnancy caused by rape or incest, and 78 percent where a woman's health — not simply her life — was undermined by pregnancy. The bill excludes those three scenarios.

The poll of 1,000 people this week across the Republic of Ireland, a country of 4.6 million, had an error margin of 3 percentage points.