Individual staff members found to be at fault in the Savita Halappanavar case may be referred to their regulatory authorities, it has been confirmed.

The HSE review report into the death of Savita Halappanavar last October,, published today, is to be referred to the Medical Council and the Nursing and Midwifery Board, Health Minister James Reilly has confirmed.

HSE officials and hospital management, at the launch of the report today, indicated that the issue of considering disciplinary or regulatory action against individual staff was unlikely to be dealt with until all the relevant reports into the Savita case, including the forthcoming HIQA report, and the coroner's inquest findings, had been considered.

However, the Minister today indicated he wanted this process to be speedier.

Minister Reilly said his Department was forwarding the report to both professional bodies 'for their early consideration and advice on any action considered appropriate, as the report raises several important issues in relation to professional practice.'

He is also calling in the Institute of Obstetrians and Gynaecologists to discuss the implications of the report.

No individuals are identified or held individually accountable in the report, for legal reasons.

The report identified major failures in the care of Savita at University Hospital Galway (UHG), specifically relating to poor monitoring of her rapidly deteriorating condition and failure to adhere to existing clinical guidelines for sepsis management, and also stressed the need for clear legal and clinical guidelines to provide clarity in cases such as Savita's.

The report says these guidelines include good practice rules in relation to expediting delivery for clinical reasons, including medical and surgical termination based on available expertise and feasibility consistent with the law.

The report says the interpretation of the law in relation to lawful termination in the Savita case, particularly the lack of clear guidelines and training, was a material contributory factor in the case.

It says similar incidents in a similar clinical context could happen again in the absence of such clarity as to where it may be necessary for a doctor to consider a termination in the clinical welfare interest of the patient.

The report says there was an immediate and urgent requirement for a clear statement of the legal context in which clinical judgement can be used in such cases in the best welfare interests of patients and for guidelines relating to this to be produced.

However, the Chair of the inquiry, Prof Sabaratnam Arulkumuran, indicated at the launch of the report that legal changes may need to go further than the Government's current proposals to deal with cases where the patient's condition can deteriorate rapidly.

The report says a major causal factor in the Savita case was inadequate assessment and monitoring that would have enabled the clinical team to recognise and respond to signs that the patient's condition was deteriorating due to infection associated with failure to devise and follow a plan of care for Savita.

This plan should have been cognisant of the fact that the most likely cause of Savita's 'inevitable' miscarriage was infection, and the risk of infection and sepsis increased with time, especially following the spontaneous rupture of membranes.

The review group said there was a failure to offer all management options to a patient experiencing inevitable miscrriage at an early stage of her pregnancy, where the risk to the mother increased with time from the occasion where the membranes were ruptured.

There was a non-adherence to clinical guidelines related to the prompt and effective management of sepsis, severe sepsis and septic shock when it was diagnosed.

Prof Arulkimaran, at the launch of the report, stressed how rapidly a patient can progress from sepsis to severe sepsis to septic shock over a very short period of time. He said sometimes, if an intervention was made at a later stage, it would be difficult 'to bring the patient back'.

Asked why guidelnes for monitoring and managing severe infection might not have been followed, he said the fact that staff were not used to dealing with such cases on a daily basis would have been a factor.

"It is such a rare problem that people were not ready to act on it."

Savita died of severe sepsis at the hospital last October 28, after being admitted at 17 weeks into her pregnancy and having been found to be miscarrying. She eventually miscarried before she died.

Savita and her husband Praveen asked repeatedly for a termination earlier on during her week-long hospital stay, but this was refused on the basis that the foetal heartbeat was still present.

A crucial part of the report states that there was an apparent over-emphasis on the need not to intervene (ie. carry out a termination) until the fetal heart stopped altogether, with an under-emphasis on the need to focus appropriate attention on monitoring for and managing the risk of infection and sepsis in the mother.

The report states that UHG's own guidelines on the management of sepsis, which had been in operation at the time, outlined the importance of attempting to establish the focus of infection and to treat any obvious source.

"This guideline states that it is imperative that any infective focus should be identified, with the removal of the source of infection to be completed as quickly as possible. In this clinical context, that would be termination of pregnancy."

Prof Arulkumuran admitted that if there had been no potential legal obstacles, as an obstetrician he would have terminated Savita's pregnancy.

The HSE and UHG management has apologised to Praveen Halappanavar and his family for the events that contributed to Savita's death.

UHG said it was committed to operating to the highest standards.

The HSE said it was working to implement recommendations from the Savita report, which, the review Chairman said, should be applied nationally.

These include implementation of an early warning chart for deteriorating patients; education of staff on recognition and management of sepsis; development of national guidelines on infection in pregnancy; developing guidelines in cases of early second trimester inevitable miscarriage where there is possible rapid deteriorating of a patient from sepsis to septic shock;and improved staff communications practices.

The HSE said the early warning score system had just been introduced for maternity services.

The report also calls for legal clarification on the context in which clinical professional judgement can be exercised in the best medical welfare interests of patients.

View the full report here