The invstigative report on Savita's Death is here: http://cdn.thejournal.ie/media/2013/06/savita...<quoted text>
As,I said yesterday ..if I misunderstood your post to be referencing our talk about pain legislation ..sorry.
I had posted already on the IRELAND lady
The Causal factors of her death are listed as follows:
Key Causal Factor 1:
Inadequate assemssemnt and monitoring that would have enabled the clinical team to recognize & respond to the signs that the patint's condition was deteriarating due to infection associated w/ a failure to devise & follow a plan of care for this patient that was stisfoctorily cognisant of the facts that:
- The most liekly cuase of the patient's inevitable miscarriage was infection and
- The risk of infection and sepsis increased wtih time following admission and especiallyfollowing the spontaneious rupture of the patient's membranes
Key Causal Factor 2:
Failure to offer all management options to a ptient experiencing inevitable miscarriage ofa n early second trimester pregnancy where the risk to the mother increased w/ time from time that embraines were ruptured.
Key Causal Factor 3:
Non adherence to clinical guidelines related to the prompt and effective management of sepsis, severe sepsis aand septic shock when it was diagnaosed.
Ultimately, each physician (and nurse) expected that the others were following up on the blood test taken when Savita was admitted to the hospital. Her white blood cell count was elevated (indicating infection). They went several days assuming no infection (she even vomited twice).
By the time they diagnosed Savita w/ an infection (E. Coli infection of the amniotic sacs) it had spread to her blood stream(sepsis).
They began antibiotics too late - and had to change them after finding out which bacteria was involved. She declined very quickly and ultimately died of cardiac failure.
Had the infection been treated when localized, it's unlikely Savita would have ended up w/ sepsis and septic shock.