Transfer patient 'beyond repair'
No intensive care bed could be found in four Irish hospitals for a young mother as she lay at "death's door" days after an emergency Caesarean section, the inquest into her death has heard.
Dhara Kivlehan died in Belfast's Royal Victoria Hospital on September 28 2010, after being airlifted from Sligo hospital where she had given birth and suffered a severe strain of pre-eclampsia.
The 29-year-old, originally from India, who moved to Co Leitrim with her husband Michael, was put on the emergency helicopter flight after consultants were told no space could be freed up in ICU in Sligo, or in Galway, Cork or Dublin.
The transfer was secured on the evening of September 24 - three days after the emergency surgery to deliver baby Dior.
Roger Murray, solicitor with Callanan & Tansey for the Kivlehan family, said by the time Mrs Kivlehan was on the helicopter to Belfast she was "effectively beyond repair" and at "at death's door".
Dr Raouf Sallam, a consultant obstetrician and gynaecologist involved in Mrs Kivlehan's care in Sligo, declined to comment on whether her chances of survival had been lost by the time of transfer.
"Obviously it's difficult to judge these things," he said.
Dr Sallam was pressed on whether he accepted that medics believed Mrs Kivlehan would die as the airlift transfer was finalised but only said: "She was a seriously ill lady."
Mrs Kivlehan was flown out of Sligo at 11pm on September 24.
Dr Sallam, who earlier branded a 12 hour delay in reviewing Mrs Kivlehan's first set of blood tests a mistake, said he had been anxious to have his patient moved to ICU the day before the transfer.
The consultant said he was sorry his concern was not noted on medical records.
Medics acted as though Mrs Kivlehan was suffering pre-eclampsia, which occurs in 15% of pregnancies, the inquest was told.
Mrs Kivlehan went on to suffer a severe variant called Hellp (haemolysis, elevated liver enzymes and low platelets) which occurs in 5% to 10% of pre-eclamptic pregnancies.
Dr Sallam told the hearing there was no cure for Hellp, other than to deliver the baby, as the condition was pregnancy induced.
He said out of around 1,500 babies delivered at Sligo in 2010, only a handful of mothers presented with the condition.
Mrs Kivlehan's case was described as more unusual than most.
Dr Sallam denied he had been involved in a blame game with Mrs Kivlehan's widower as he pressed doctors for answers on why his wife had not been taken to ICU.
"I did not comment on anything in the ICU because I do not have the expertise to comment," he said.
"I swear to God I did not criticise."
The inquest at Carrick-on-Shannon courthouse was told a range of blood tests over the first 36 hours of Mrs Kivlehan's care examined 17 parameters and showed kidney failure and liver dysfunction.
She was also suffering serious issues with her blood, such as clotting, water and urine, according to the results.
Dr Sallam said the tests taken on her admission to Sligo on September 20 2010 should have been reviewed as soon as possible.
"There's an error happened here," he said.
"These results should have been reviewed and acted upon," he said.
The inquest heard blood samples were sent to the laboratory at 4.30pm on September 20 2010 and were available on an internal computer system for doctors and nurses by 5.23pm.
They were not reviewed for 12 hours, according to medical records.
Dr Sallam said: "The normal circumstance is that if there's a high suspicion of serious problems, these bloods should be traced quickly by whoever took them."
The consultant, who went on to work at South Tipperary General Hospital after Sligo, was in the theatre when the Kivlehan's baby, Dior, who turned four last Sunday, was delivered by C-section.
He told the inquest the delivery was classed as a category two Caesarean as there were concerns the mother's or baby's health was being compromised but there was no immediate threat to life.
The inquest heard the young mother showed signs of acute kidney failure and liver dysfunction on the day she had the emergency C-section.
Health Service Executive (HSE) guidelines state that a patient suffering with problems affecting two organs should be cared for in an intensive care unit.
Midwife Mairead Beirne revealed that a registrar on the obstetrics team, Dr Hind Al Husain, wanted her concerns recorded that Mrs Kivlehan should be in ICU the day after the delivery.
"She asked me to formally record her anxiety about moving Dhara to ICU," the midwife said.
"That was her position."
Ms Beirne said she was not aware of all the detail of a conversation he had with a senior consultant on the anaesthetics team, Dr Seamus Crowley.
Mr Kivlehan told the inquest on Monday that Dr Crowley said it was difficult to tell if his wife was jaundiced from her appearance because she was Indian.
The HSE claimed his assessment was much more nuanced than being based on whether a patient had pale or dark skin.
The inquest takes place in the week leading up to the fourth anniversary of Mrs Kivlehan's death.
Widower Mr Kivlehan, from Dromahair, Co Leitrim, and his son Dior were awarded almost one million euro last year after the HSE apologised for shortcomings in the young mother's care.