'Misadventure' verdict on mother
A first time mother who died a week after an emergency Caesarean section lost her life in medical misadventure, an inquest jury has found.
Dhara Kivlehan, 29 and originally from India, died in Belfast's Royal Victoria Hospital on September 28 2010 after being airlifted from Sligo hospital where she had given birth a week earlier and suffered a severe strain of pre-eclampsia.
The five day hearing at Carrick-on-Shannon courthouse heard deficiencies in her care included a 96 hour delay in a kidney specialist assessing her critical condition and a 12 hour gap in the first set of blood tests being reviewed.
Yesterday was the fourth anniversary of Mrs Kivlehan's death and a week since her son Dior turned four.
The young mother died on the fifth anniversary of her marriage to Michael Kivlehan in a wedding in his wife's home province of Gujarat, India.
Her death was recorded as 2.10pm in the afternoon, the same time as the service.
Widower and full-time father Michael, supported by his mother Susan and father Michael senior, said the inquests was about getting answers.
"We had no answers up to now. Even though it came to litigation we weren't allowed answers in our day in court, to get the feel for where things went wrong," he said.
"We knew the answers as to how Dhara died and we had the best medical experts in the world and in the inquest they have more or less said the same thing.
"We have clarity now but in a curtailed fashion."
The Health Service Executive (HSE) said the delay in checking the blood results was a shortcoming.
The agency apologised on behalf of Sligo hospital at a civil case in the High Court last year where Mr Kivlehan and baby Dior were awarded almost one million euro (£780,000) in damages.
"Again on behalf of the management and staff of Sligo hospital we would like to take this opportunity to repeat this apology and reiterate our sincere condolences," the HSE said in a statement.
Mrs Kivlehan died from multi-organ failure as a result of suffering Hellp syndrome - Haemolysis, Elevated Liver Enzymes and Low Platelets, the severe strain of pre-eclampsia.
The jury, after bringing in their unanimous verdict, added a number of recommendations to coroner Eamonn MacGowan.
They include the establishment of national database for vacant intensive care beds at all national and regional hospitals and a new rule to order all senior doctors who attend theatre to sign a register.
The jury also said all blood tests ordered should be reviewed by the same doctor and when they are of a critical nature they should be flagged to the laboratory.
Mrs Kivlehan was admitted to Sligo hospital on September 20 and underwent an emergency C-section the next morning.
She was due to be moved to an intensive care unit following the surgery but this did not happen for another 24 hours.
Mr Kivlehan, 35, from Dromahair, Co Leitrim, complained during the inquest about the manner in which he was spoken to by an ICU consultant while in Sligo and that his wife had not been cared for in intensive care.
On the night of September 24 she was airlifted from Sligo to the Royal in Belfast as no intensive care bed could be found for her in an Irish hospital.
She died there four days later.
In a statement, a spokesman for Sligo hospital confirmed that no disciplinary process took place in relation to Mrs Kivlehan's death.
"We will now review the coroner's verdict and decide if this approach is appropriate given all of the circumstances," he said.
Outside Carrick-on-Shannon courthouse Mr Kivlehan revealed plans to set up a foundation to support other single fathers whose wives or partners die in similar circumstances.
The widower was also accompanied by Sean Rowlett, whose wife also died after giving birth at Sligo hospital. His wife Sally, 36, of Dromore West, Sligo, died on February 5 2013 after giving birth to her fourth child and suffering Hellp.
An inquest into her death is planned for December.
Mr Kivlehan said he felt vindicated, a feeling backed by comments from the coroner to the Kivlehan family at the end of the lengthy hearing.
"I wish them and their family and friends peace, tranquillity and contentment into the future," Mr McGowan said.
"Michael has vindicated Dhara's life and explained her life through his campaign to have the inquest held. I'm sorry it has taken four years to do so."
At the final day's hearing Dr Peter Boylan, consultant gynaecologist and obstetrician and former master of the National Maternity Hospital, was called as an expert witness and said staff and ICU bed shortages were among the failures in Mrs Kivlehan's care.
"Having reviewed the medical notes from Sligo and Belfast and having read the statements provided to the inquest by those involved in Mrs Kivlehan's care, it is clear to me that there were deficiencies both in her clinical care and at a systemic level," the doctor said.
The medical file on Mrs Kivlehan's care in Sligo shows efforts were made to find beds in ICU at St James's and St Vincent's in Dublin on September 24, the day of transfer to Belfast. Unsuccessful attempts were also made to find an ICU bed in Galway and Cork.
Dr Boylan said it was hard to say if an earlier transfer would have made a difference.
"Unfortunately if she had have been transferred earlier it might have made a difference but it's hard to say," he said.
The HSE clinical review report one month after Mrs Kivlehan's death called for a database to be set up to constantly monitor the availability of ICU beds nationwide.
It has not been done due to a lack of resources, the inquest heard.
Dr Boylan criticised consultant shortages across the health service and said it was well recognised that Ireland has the lowest number of consultant obstetricians per capita than other countries in the OECD group.
"I'm aware there's a lack of consultation in all units in Irish hospital and Sligo is no different in that respect," Dr Boylan said.
The inquest heard pre-eclampsia occurs in 10% of pregnancies with varying degrees of severity. Up to one fifth of those develop into Hellp.
Estimates put the occurrence of Hellp at six in every 1,000 pregnancies while the death rate for the condition is around 1%.
Dr Boylan said it was his opinion that the deficiencies were both in the clinical care given to Mrs Kivlehan and systemic failures in the health service.
He said they also included the attribution of all of Mrs Kivlehan's problems to Hellp syndrome.
Although Mrs Kivlehan died in Belfast, the inquest was moved to the Republic of Ireland after Attorney General Maire Whelan intervened to ask Belfast coroner Dr John Leckey if he would agree to a change in jurisdiction.
Michael and Dhara Kivlehan met in a nightclub where they were both working while living in London and had married and moved to raise a family near his family home in Dromahair, Co Leitrim.
The single father now retains strong relations with his late wife's family in Ahmedbad, Gujarat province and baby Dior speaks to relatives via Skype on an almost daily basis.
Dr Boylan did however reserve some criticism for the doctors in Sligo for not examining in further detail suspicions, which were marked in the medical notes, that Mrs Kivlehan had suffered abdominal bleeding after surgery.
"I think it was an error of judgment, in that time she was obviously getting very seriously ill," he said.
"The picture was complicated then and I do think it was a deficiency and an error of judgment, whether it had any major contribution to her death is a difficult thing to talk about."