22 April 2013

Who controls the past, controls the future...

It’s astonishing to look at the reaction of so many people in Ireland to the recent inquest into the death last October of Savita Halappanavar in Galway, and in particular at how so much attention is being paid to Dr Peter Boylan, erstwhile master of the National Maternity Hospital, that the inquest seems to be being rewritten in the popular mind.

Everyone seems aware of what Dr Boylan said at the inquest, but in directing the jury towards its verdict, the coroner didn’t so much as acknowledge Boylan’s claim that Savita would have survived if the law permitted doctors to terminate pregnancy in order to pre-empt hypothetical risks rather than real ones.

The jury could, of course, have disregarded the coroner's advice and given a narrative verdict which would have given due weight to Dr Boylan's belief that the law was the problem. Instead it opted for a verdict of medical misadventure, accepting the coroner's recommendations, the emphasis of which was almost wholly on procedures and systems failures, with the sole reference to terminations being a recommendation that the Medical Board and An Bord Altranais should have a common, clear, and explicit set of guidelines for how situations such as Savita’s should be handled. It looks, in truth, as though the inquest implicitly rejected Boylan’s analysis.

The official response from Galway University Hospital seems to recognise this, with lots of browbeating about systems failures and not a word said about the law putting Galway's staff in an impossible position.

If the inquest implicitly rejected Boylan’s analysis, Savita’s widower Praveen seems to have gone rather further, going so far as to cast aspersions on Boylan’s integrity.

Praveen's View
Interviewed by the Irish Times, Praveen stated that he believes Dr Katherine Astbury, the obstetrician who was in charge of Savita’s case, used the law as an excuse, a scapegoat for Galway’s poor handling of the case, and suggested that Boylan, by determinedly attributing Savita’s death to a failure of law, was effectively covering for her.
"Well everyone has their opinion. He's a doctor. I think he was soft on Astbury. I was told the obstetricians' is a small world and they all know each very well. I don’t know. It looked like he came across very soft on her."
Although Katherine Astbury trained at the National Maternity Hospital, among other hospitals, it should be pointed out that Peter Boylan says he does not know her. It’s intriguing that those who were so keen to make Savita a martyr for the pro-choice cause have been rather quiet about her husband questioning the integrity of the one obstetrician who keeps pushing the idea that Savita's case shows a need for a profound change in the Irish law, far beyond legislating for the X judgment.

I watched Boylan reel off his spiel on Prime Time on Friday night, and listened to him on Marian Finucane yesterday; I was too busy to experience him a third time this evening on Vincent Browne, but irked by his contemptuous conduct yesterday, and with my work done for the night, I think it’s worth highlighting a few issues with things he’s said over the last couple of days.

British Abortion Law: A Basic Primer
Boylan burbled away yesterday about terminating a pregnancy on hypothetical grounds being illegal in Ireland but legal anywhere other than theocracies. This simply isn’t true. Let’s take Britain for example, as that’s the nearest jurisdiction where abortion is routinely available, and the one in which more than 4,000 Irish women have abortions in any given year – a horrendous figure, but one that's been in steady decline for years, probably reflecting the long overdue demise of the cruel and unjust stigma against single mothers that used to mark the popular mind at home.

Now, I'm not saying a British doctor wouldn't terminate on the grounds of hypothetical harm, but I am saying they'd probably be breaking the law if they did so and would only get away with it because the British system is poorly audited and basically assumes doctors act in good faith.

If Peter Boylan had been in Britain and terminated the pregnancy of a woman he believed to be physically and mentally well, there's a good chance he'd have been in breach of the 1861 Offences Against the Person Act.

Here’s the thing most Irish people don’t get, which enables all manner of people to muddy the waters: abortion is not legal in Britain.

I know, roughly 200,000 human beings are killed in Britain every year whilst still in their mothers’ wombs, but the fact is that the 1861 Act forbids abortion. The 1967 Abortion Act did not legalise abortion; rather, it provided doctors with a series of defences that could be used to justify the performance of abortions on medical grounds.

There are seven such defences, and it’s worth looking at them with a view to seeing how Savita’s request for a termination as she wanted the ordeal over with might have been understood.

Grounds F and G relate to clinical emergencies, where a pregnant woman’s life is in danger or there is a grave threat of permanent injury to her physical or mental health; as Boylan makes clear, there was no emergency until Wednesday, so these grounds wouldn’t apply.

Grounds A and B relate to situations which are not clinical emergencies but where termination is deemed necessary to prevent loss of life or grave permanent injury; again, these was no evidence of any such threat before Wednesday, so these grounds wouldn’t apply.

Ground E permits terminations where the child is expected to be born with a severe handicap, but the histopathologist Dr Michael Tan Chien Shang reported that the child had been perfectly healthy and normal; there was even, as Boylan has admitted, a chance she might survive and come to term.

Ground D concerns risk to any existing children of the pregnant mother; as Savita had no children, this ground clearly wouldn’t have applied.

This leaves ground C, upon which the justifications for 98pc of British abortions rest. This allows terminations when the pregnancy has not exceeded its twenty-fourth week and where its continuance would be more dangerous for the pregnant woman than the termination of pregnancy.

Note that as far as Boylan was concerned, Savita was well until Wednesday*; assuming he believes this was the case, it is difficult to see on what basis he would argue that it would be have been better practice to expose her to risk through abortion than allowing her to give birth or miscarry naturally, given that the risks the latter option posed were purely hypothetical.

If a Ground C defence were to be legitimate it would almost certainly have to rest on the claim that terminating the child she wanted would have been less harmful to Savita’s mental health than seeing what would happen. Almost all Ground C terminations – 99.96pc of them – take place on mental health grounds, despite the RCOG pointing out that the evidence shows that abortion does not help people's mental health.

As Dr David Walsh explained on Vincent Browne last November, “the interventions carry risk as well as the non-interventions.”

What did Professor Bonnar say?
Interruptions were pretty much the hallmark of Dr Boylan’s Marian Finucane performance, and cutting in to ‘correct’ Breda O’Brien, he struck me as having rather egregiously misrepresented Professor John Bonnar, former chairman of the Institute of Obstetricians and Gynaecologists, with whom he’d discussed these matters on RTE’s Prime Time on Friday night.

“That’s incorrect,” butted in Boylan on Breda, explaining, “I was on Prime Time with him there last night I think it was…Friday night. And that’s not correct what he said. He said he would wait until she was ill and then he would have no hesitation in intervening… He was very clear about that because I picked him up on that.”

This simply isn’t true. John Bonnar did not say doctors should wait till a patient is ill before acting; he said they should find out if a patient is ill and then act.

Bonnar has said that had proper tests been carried out the hospital would have had evidence of substantive risk by Tuesday, and that this evidence would have justified termination. In other words, unlike Peter Boylan, and with microbiologist Dr Susan Knowles and apparently the Coroner, John Bonnar takes the view that the issue was systems failures and mismanagement, not law:
"My concern would be that the tests for infection were not heeded. There should have been swabs taken when she was admitted, we should have identified what the organisms were, we should have started the antibiotic treatment, and then terminated, and that could have been done by Tuesday."
Boylan’s response to this was simply to pull a sceptical face, while saying “John. Come on.” Like so.

Good eyebrow action. Always works well in the absence of an argument.

Note that Boylan hasn’t rebutted or refuted this argument; he’s merely looked condescendingly at another obstetrician, and then subsequently misrepresented what he said.

And remind me – what exactly did Dr Knowles say?
Earlier in the Prime Time discussion, Peter Boylan said something very odd.

“To me the deficiencies were mainly in appreciating that the ruptured membranes may well have been due to chorioamnionitis –" began Bonnar.
“There was no sign of that whatsoever,” butted in Boylan, “until the early hours…”

The thing is, that’s not quite true, and Peter Boylan should know this, given his supposedly forensic scrutiny of the case files and how he received transcripts of all testimonies at the inquest. He wasn't, after all, the only expert witness at the inquest.

Dr Susan Knowles was the consultant microbiologist who gave expert testimony to the inquest, and given that the whole Savita affair was basically a story of infection, I'd have thought her testimony should be given at least as much scrutiny as Peter Boylan's. She was, as Muiris Houston put it in The Irish Medical Times, a "beacon of light" at the inquest. She made several important points in this regard during her evidence.
  • Firstly, she said that the Sunday blood test suggested that Savita’s body might have been fighting a subclinical infection even before her membranes ruptured, and that this test should have been followed up properly.
  • Secondly, she pointed out there were “subtle indicators” of sepsis and chorioamnionitis on Tuesday.
  • Thirdly, she made clear the antibiotic treatment Savita received prior to lunchtime on the day she lost her child was less comprehensive that what she would have received in any of the Dublin maternity hospitals and didn't meet Galway's own standards.
I realise that Dr Boylan has argued that the initial Sunday blood test probably didn’t mean anything, but I don’t think it makes sense simply to act as though the testimony of another expert witness – who happens to be a colleague of his at the National Maternity Hospital, as well as one of the country's leading experts on infection in pregnant women – simply didn’t happen.

Besides, even if Boylan were right to say that there was no evidence of chorioamnionitis before Tuesday, this would hardly negate Bonnar’s point that evidence of such things simply wasn’t looked for. As Dr Knowles pointed out, the Sunday blood test should have been followed up!

And, for those who are determined to support experts who say what we want to believe...
I’m loath to point to her, given her comments on the Savita affair have been sometimes prone to disregarding facts and to have shown a surprising misunderstanding of details that were in the public domain, but it might be worth looking at what the American pro-choice doctor Jen Gunter has said on this issue.

On 9 April she wrote that Savita’s combination of ruptured membranes, dilated cervix, and an elevated white blood cell count – all of which were in play by the early hours of Monday – all point towards a diagnosis of chorioamnionitis. On 13 April she added that the facts that Savita had an elevated heart rate –  on Tuesday evening –  and shaking chills –  by the early hours of Wednesday –  suggested that the infection had spread from her uterus into her blood stream as a result of chorioamnionitis being inadequately treated.

Now, I’ve been sceptical of Dr Gunter’s approach to this stuff, but I’ve seen pro-choicer after pro-choicer citing her with approval ever since the Savita story broke. If she’s even remotely credible, we have to at least recognise that her thesis poses a serious challenge to Dr Boylan’s claims.

To be honest, I think Dr Knowles’s testimony is challenge enough.

For the record, it's not Breda O'Brien who's been rewriting history...
Dr Boylan was very quick on yesterday's Marian Finucane to correct Breda O’Brien when she said that Savita had been admitted to hospital with her cervix fully dilated. He may well have been factually correct to point out that Breda was wrong, but it was both churlish and inaccurate of him to describe Breda’s point as “revisionism and the rewriting of the history of what actually happened”.

The problem is that even if Boylan is right to say that Savita’s cervix was not fully dilated when she was admitted – and he should know, as unlike most people, he’s had full access to Savita’s medical records – this isn’t what Praveen said back in November.

The Irish Times twice in November cited Praveen as saying that when Savita was admitted “The doctor told us the cervix was fully dilated, amniotic fluid was leaking and unfortunately the baby wouldn’t survive.”

Dr Olutoyele Olatunbosun, the gynaecology SHO who treated Savita on the Sunday told the inquest that she had found that Savita's cervix was dilated, and when addressing the inquest on 9 April, Praveen stated that when Savita was admitted she was told that there was “some cervical dilation”.

There may well be some revisionism – some rewriting of history – going on with this part of the story, but it’s not been Breda O’Brien who’s indulged in it. If Breda and her obstetrician friends can be faulted here, it’s for having trusted the original story as told by The Irish Times, and not having caught its most recent incarnation as told by Praveen.

Revisionism isn’t necessarily a bad thing, by the way. Sometimes we discover new facts or think of new questions, and these should force us to revise our old views and old narratives. That's just being honest and being thoughtful. Hanging onto "the crippling version of this story that was initially presented to the country by The Irish Times, which sought to shape this woman's tragic death into a rallying cry for a change to Ireland's abortion laws", would be neither honest nor thoughtful.

But that’s by the by.

Failings, failings everywhere...
Another oddity on Marian Finucane took place when Dr Boylan claimed that the only thing that the inquest identified as being deficient in the first two days was "the lack of a repeat of a white cell count".

That may have been the only thing he identified as deficient in the first two days, though even then he played down the significance of that, but it simply wasn’t the only thing the inquest identified as deficient in that period.

The coroner recommended – and the jury strongly endorsed this view – that blood tests should always be followed up properly, with procedures in place to make sure such errors as happened don't occur, and that there should be proper communications between hospital staff. Now...
  • Susan Knowles noted that Savita was not given a vaginal examination or checked for leaking of amniotic fluid on the Sunday.
  • The failure to follow up the blood test Dr Olatunbosun ordered on the Sunday meant the hospital's treatment of Savita was conducted in the assumption that Savita was not already fighting infection, whereas she may already have been afflicted with a subclinical infection.
  • Dr Andrew Gaolebale said that he was not informed of the results of the Sunday blood test and he was not told that her membrane had ruptured after he saw her, even though he was still on duty for another 12 hours into the Monday.
  • I don't know if Tuesday evening counts as being within the first two days, but just over 48 hours after Savita was admitted there seems to have been an issue with information about Savita's elevated pulse being brought to Dr Ikechukwu Uzockwu by the midwife manager Ann Maria Burke; we don't what happened, as their evidence is contradictory, but it seems that something went wrong with tachycardia, a classic sign of sepsis, not being taken properly into account.
To this I'd add that when Peter Boylan asked Breda, "Which is what? What have your colleagues – your obstetrician colleagues – identified as proper care?", I cannot help but recall how John Bonnar's answer, quoted above, sums up what he believed ought to have happened, had the white blood cell issue been spotted, perhaps in connection with Dr Gaolebale been told in a timely fashion of how Savita's membranes had ruptured since he'd inspected her, with her collapsing and vomiting.

It’s striking how Dr Boylan cuts Breda O’Brien short and misrepresents her as saying that an elevated white blood cell count would have justified a termination; she had never said any such thing.

What she was clearly trying to get at, though, was that if this had been spotted –  as Susan Knowles said it should have been, and indeed as was obviously the case from the HSE leaks some weeks ago –  it could have justified a whole series of other steps, as outlined by John Bonnar, which in turn might have justified a termination in accord with Irish law and normal Irish medical ethics.

I'd also point out that if the New York Times has reported things accurately, Dr Astbury herself, like Dr Knowles and evidently Dr Bonner, gave rather more weight to the failure to follow up the Sunday blood test than Dr Boylan did.
"The inquest has also heard testimony that several hospital protocols were not followed, amounting to system failures that contributed to Dr. Halappanavar’s death. Dr. Astbury said she might have intervened sooner had she been made aware of the results of earlier blood tests."
She presumably didn't mean she'd have leapt in to terminate or accelerate the miscarriage, but rather would have taken steps to find out what was going on  – steps that could have found out just how sick Savita was, regardless of how she appeared, and that would have necessitated decisive action. It's nonsense for  Peter Boylan to say there was no other evidence of problems; there was no evidence because the evidence wasn't sought.

As John Bonnar has said, there were ways of seeking that evidence.

* No, really. That's the central plank of his argument. 44 minutes into Marian Finucane, for instance, he tried to explain away Galway’s failure to terminate Savita’s pregnancy before Wednesday morning by saying it’s an issue of law and clearly stating “She was well till then – that’s the issue, you see.”

This seems, at best, a presumption, as if she really had been well till Wednesday, then we must assume that she developed her infection on Wednesday. The reality, clearly, is that she merely appeared well, while harbouring a serious infection that had yet to kick in in a serious way.

That the white blood cell was high on Sunday may well have indicated that she had arrived in hospital fighting a subclinical infection, according to Susan Knowles, who is adamant that the test should have been followed up. Even without following up the test, and conducting further tests along the lines suggested by John Bonnar, who suspected that the rupturing of Savita’s membranes just after midnight on Monday may have been due to chorioamnionitis, it’s clear the hospital had recorded  'subtle indicators' of sepsis and chorioamnionitis before Wednesday, however, including a high pulse rate on Tuesday, according to Susan Knowles.

1 comment:

Conor McWade said...

So you are saying that a termination should have taken place on Tuesday (or before) and that this would have been a legal termination? Or are you saying they could have treated the infection if they had acted earlier and with better antibiotics?