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Phelim Quinn of HIQA Sam Boal/Photocall Ireland

'Disturbing similarities' between Savita and Tania McCabe deaths

Only five of the 19 maternity units in Ireland have learned from the tragic deaths of the garda sergeant and one of her twin boys.

TANIA MCCABE WAS six months pregnant when she was admitted to Our Lady of Lourdes Hospital, Drogheda in March 2007.

Her waters broke prematurely but she was discharged from the maternity unit the next day. She was readmitted to the hospital less than 24 hours later.

Her twin boys, Zach and Adam, were born by caesarean section that night. However, Zach had severe congenital abnormalities and soon died in his mother’s arms.

The 34-year-old, who was a garda sergeant, then suffered a post-partum haemorrhage. Despite emergency surgery, she died at the hospital after going into septic shock.

A later High Court action claimed negligence on the part of the hospital and obstetrician because they had failed to diagnose that her waters had broken, wrongfully discharged her and did not recognise septic shock on readmittance.

In the third damning report into the death of Savita Halappanavar in Galway last year, the Health Information and Quality Authority (HIQA) found that very little had been learned from the tragic events.

“The findings of this investigation clearly show that where responsibility for implementation of learning is not clearly owned, then learning does not happen,” HIQA’s Phelim Quinn said.

This is demonstrated in the findings relating to the HSE inquiry into the death of Tania McCabe and her son Zach in 2007, the circumstances of which have a disturbing resemblance to the case of Savita Halappanavar.

The similarities between the two cases was “probably one of the most disturbing findings” of the probe, the Director of Regulation told reporters yesterday during a briefing.

As part of the investigation into the death of Savita Halappanavar, HIQA requested the HSE to provide details of how the recommendations of the report into the circumstances of the 2007 deaths had been implemented at each of the 19 public maternity units.

Of the 19, only five provided a details status update for all 27 recommendations of that report. They were the Midland Regional Hospital Mullingar, Coombe Women’s and Children’s Hospital, the Rotunda, Our Lady of Lourdes Drogheda and the Mid-Western Regional Maternity Hospital.

Of the remaining 14 – including University Hospital Galway – six reported their status against a different investigation or gave no comment. A number of the six reported that evidence for implementation was not in existence.

“This is unsatisfactory and concerning,” said the report, while Quinn described it as “unacceptable”.

“Both senior managers within every maternity hospital in Ireland, and the corporate HSE, are responsible for implementing this fundamentally important learning and should be held to account in doing so,” he continued.

image

Adam McCabe and his father Aidan ,widow of the late Garda Tania McCabe, looking at the Giraffe Omnibed Incubators donated by the McCabe Foundation to Holles St Hospital at a function in Garda Headquarters, Dublin last year.

One of the recommendations asked the HSE to adopt the international Surviving Sepsis Campaign to build awareness, encourage early recognition and standardise treatments.

The responses from hospitals across the country indicated a regionalised rather than national approach to the recommendations.

This lack of a coordinated approach raises a “fundamental and worrying deficit in our health system” again, said HIQA.

“Namely the ability to implement and apply system-wide learning from adverse events across the system in a timely and appropriate manner in order to prevent the recurrence of patient safety events that may cause harm, or worse, to future patients.”

Although HIQA does not have enforcement powers, Quinn said the 34 recommendations of the report into the treatment of Savita Halappanavar will have to be implemented satisfactorily.

“At the minute, we have very limited information to get any level of assurance,” he said. “There is a very significant emphasis on the requirement, firstly for local recommendations to be implemented in Galway, but they also need to be taken on board in other hospitals across the country.

“We have been having ongoing dialogue with the HSE…I think our recommendations do constitute a significant reminder to the HSE.

I don’t think the Irish healthcare can afford to keep missing these opportunities to get things right.

CEO of HIQA, Dr Tracey Cooper, added that the principals of yesterday’s report also relate to other non-maternity services and noted a recommendation that every healthcare provider self-assess their guidelines and protocols against the report’s findings.

The report found that there were 13 clear opportunities to intervene in the care of the 31-year-old dentist which could have changed the outcome of her treatment last year.

image

It concluded that there was “a failure in the provision of the most basic elements of patient care to Savita Halappanavar and also the failure to recognise and act upon signs of her clinical deterioration in a timely and appropriate manner”.

The hospital has since apologised to Praveen Halappanavar and family for the care Savita received in October 2012.

Read: Damning Savita report details litany of hospital care failures

See: This shocking graph shows 13 “missed opportunities” in treatment of Savita

Related: University Hospital Galway apologises to Praveen Halappanavar and family

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46 Comments
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    Mute KM TON
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    Dec 1st 2016, 1:14 PM

    I feel bad for people losing their jobs but this is the least surprising news ever. The only bit i of a surprise is that it lasted this long.

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    Mute Veroníca
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    Dec 1st 2016, 5:58 PM

    I’m surprised like you that it survived this length of time considering it was utter rubbish anyway

    11
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    Mute Alex Simms
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    Dec 1st 2016, 2:16 PM

    And so concludes the worst idea in Irish television history…

    152
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    Mute Neal, not Neil.
    Favourite Neal, not Neil.
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    Dec 1st 2016, 5:34 PM

    You forgot about Channel 6.

    17
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    Mute Dave O'Hanlon
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    Dec 1st 2016, 6:28 PM

    Channel 6 was actually a decent idea, a channel aimed primarily at a young adult audience. The problem was when it got taken over by TV3 and turned into 3e. They could easily have kept it the way it was but no instead of looking at Michelle Doherty showing decent music videos there was yet more Ant & Dec with X factor loonies

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    Mute Irish Cottage Rental
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    Dec 1st 2016, 1:33 PM

    One island two UTV’s
    A endless farce.

    139
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    Mute Carm(Orange Vampire)
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    Dec 1st 2016, 2:33 PM

    Does this mean that the real ITV/Ulster TV will be available to Irish viewers again?

    110
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    Mute David Walsh
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    Dec 1st 2016, 2:51 PM

    @Carm(Orange Vampire): There’s no legal obligation on TV carriers in Ireland to carry any of the ITV franchises so it’s probably not going to happen. In any case the ITV shows licenced to the TV3 group would be liable to geo locking; that would make it as good as a non option to carry UTV/ITV here so all you’d get is Julian or Good Evening Ulster. Certainly Virgin Media would have no incentive to carry it, they being its opposition.

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    Mute Seán J. Troy
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    Dec 1st 2016, 4:23 PM

    @David Walsh: Didn’t the EU just pass a bill that ends geoblocking within the EU?

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    Mute John Flood
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    Dec 1st 2016, 4:26 PM

    Julian on camera is no longer on the air. He does prerecorded voice overs controlled by ITV HQ. Changed a couple of weeks ago.

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    Mute Screaming Toddy
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    Dec 1st 2016, 4:56 PM

    UTV will never be on Virgin again. Why would Virgin have a competitor showing the same rubbish stuff on their rubbish channels

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    Mute David Walsh
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    Dec 1st 2016, 11:45 PM

    @Seán J. Troy:

    1) It is only a draft resolution and not a law as of yet
    2) It excludes copyright protected services; this included media and broadcasting.
    3) UK will soon be outside of the EU and not regulated by EU laws.

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    Mute Gavin Redmond
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    Dec 1st 2016, 1:21 PM

    Created to fail. Somethings just don’t work.

    79
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    Mute Owen Hennelly
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    Dec 1st 2016, 1:45 PM

    So will it stay on as a third TV3 channel or be wound up altogether? If it’s wound up will we be getting UTV NI back in its place?

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    Mute Paul Furey
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    Dec 1st 2016, 3:58 PM

    UTVNITV3

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    Mute Seán J. Troy
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    Dec 1st 2016, 4:23 PM

    @Paul Furey: I heard of that one, it’s a an African rebel group.

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    Mute Neal, not Neil.
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    Dec 1st 2016, 5:29 PM

    @,Seán the geoblocking thing was more about making sure that your can access your Irish Netflix or Sky on demand content while temporarily visiting another EU country

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    Mute Larry Doyle
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    Dec 1st 2016, 1:54 PM

    Great – even more Jeremy Kyle repeats!

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    Mute Tom Harpur
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    Dec 1st 2016, 2:54 PM

    A few years back TV3 had plans to start 3 classics 3 kids 3 sports and TV3+1 and a Sony HD Studio they commenced the Studios but scrapped the extra channels so maybe now they’ll rebrand UTV to 3 Classics or 3 sports.

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    Mute Neal, not Neil.
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    Dec 1st 2016, 5:31 PM

    It would be very interesting to see what a TV3 “cassic” is. Perhaps a selection of Vincent Brown’s crankiest episodes?

    21
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    Mute John Flanagan
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    Dec 1st 2016, 3:33 PM

    UTV Ireland didn’t serve the deaf & hard of hearing community well because when it was first launched, there were no subtitles to be had at the time. Glad to see this god-awful channel go because of endless repeats as well!

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    Mute Screaming Toddy
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    Dec 1st 2016, 4:57 PM

    What?

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    Mute Scot Tanner Buchholz
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    Dec 1st 2016, 11:38 PM

    That is not the fault of the TV station rather a fault in Ireland not having ‘CC’ services like they have in Canada and the U.S.A. CC = closed captioning. The technology is out there. Ireland just lags behind in using it.

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    Mute Mick Mccomiskey
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    Dec 1st 2016, 2:53 PM

    This is very disappointing. Now I won’t be able to use utv Ireland player. It had most of the stuff available on itv.

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    Mute Neal, not Neil.
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    Dec 1st 2016, 5:33 PM

    TV3 own a lot of those programmes rights for the next ten years as part of the deal so they’ll put them somewhere.

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    Mute Mike Galvin
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    Dec 1st 2016, 6:14 PM

    All I say is I wish TV3 the best of luck with the 3 channels, whatever we might say. I only wish they would upgrade their picture quality on saorview especially for large screen tvs, the same applies to TG4.

    11
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    Mute John Flood
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    Dec 1st 2016, 4:28 PM

    If you want UTV, get FREEVIEW Ireland via satellite. Best thing going. Pay for set up or DIY and NO fees afterward.

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    Mute Shane Kinsella
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    Dec 1st 2016, 4:44 PM

    You’re getting mixed up with FREESAT. Freevirw is the terrestrial TV service. Both of which are miles better than saorview.

    12
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    Mute John Flood
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    Dec 1st 2016, 4:47 PM

    both Saorview and Freeview into a single Digital Terrestrial Receiver allowing you to receive all the Free UK & Irish Digital TV Channels on a single box.

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    Mute Dónal O'Flynn
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    Dec 1st 2016, 8:32 PM

    @John Flood: you’re still missing Shane’s point. You can’t get “Freeview” here that’s only available within the bounds of the UK. What we can get is “Freesat”. The only reason we have it at all is that the satellites have to cover all of the UK and can’t do that without also covering Ireland.

    Also available for the few percent of Irish homes that can’t get “Saorview” is “Saorsat” with RTÉ 1, RTÉ 2 and TG4 only, no purely commercial telly.

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    Mute John Flood
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    Dec 1st 2016, 8:41 PM

    I just cut n pasted text from my owners manual. Apparently not all of Ireland can receive the FTA channels of the satellite. I’m in Wicklow, my friend in Cork can’t get same.

    1
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    Mute David Walsh
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    Dec 1st 2016, 11:49 PM

    @Dónal O’Flynn: there are plans on the cards to make most of the Freeview channels available to Saorview customers.

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    Mute Ciarán Masterson
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    Dec 2nd 2016, 1:27 AM
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    Mute Paddy Flynn
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    Dec 1st 2016, 3:08 PM

    TV3 2? I don’t think so.

    5
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    Mute Tiarnan Guinée
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    Dec 1st 2016, 3:49 PM

    @Paddy Flynn: 3ee more like

    13
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    Mute Scot Tanner Buchholz
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    Dec 1st 2016, 11:33 PM

    This is a sad day for freedom of the press, steps towards democracy and the people who will loose their jobs. Ireland is large enough to support Three tv stations. Rte should loose RTE2 and save tax payers money. #SadDay #UTVIreland

    3
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    Mute von
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    Dec 1st 2016, 7:51 PM

    From TV 3 Ah well we can get rid of all the people who kept us alive for months but now we have Emmerdale and Corrie dory guys we don’t meed you. Bye bye.
    And the fat cats get fatter.

    3
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    Mute Buster VL
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    Dec 1st 2016, 8:24 PM

    Aaa Wally free zone.

    1
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