Inquest told of 'care deficiencies'
One of Ireland's top consultants has said there were deficiencies in the care of a first time mother who died a week after an emergency Caesarian section.
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.
At an inquest into her death Dr Peter Boylan, consultant gynaecologist and obstetrician and former master of the National Maternity Hospital in Dublin, said staff and ICU bed shortages were among the failures.
"Having review 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.
Dr Boylan said there insufficient numbers of consultant obstetricians working at Sligo while Mrs Kivlehan was being cared for there.
The senior doctor said this led to a lack of continuity of care at consultant level.
Dr Boylan told the fifth day of hearings that there were delays in getting kidney and liver specialists to assess Mrs Kivlehan while in Sligo.
The inquest heard last week that there were delays of up to 96 hours from her admission on September 20 2010 in necessary assessments by the specialists while the first blood tests were not reviewed for 12 hours.
She gave birth to baby Dior at 6am the following morning.
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 - haemolysis, elevated liver enzymes and low platelets, the severe strain of pre-eclampsia that eventually led to multi-organ failure.
Dr Boylan said doctors failed to seriously consider the possibility of intra-abdominal bleeding in the time after the C-section and they also delayed her transfer to a tertiary centre, ideally St Vincent's University Hospital Dublin.
The consultant said the systemic failures included the lack of prompt availability of specialist renal and liver input at Sligo hospital and lack of intensive care beds in Dublin or Galway.
The Health Service Executive (HSE) clinical review report from late 2010 on Mrs Kivlehan's death had called for a database to be set up to constantly monitor the availability of ICU beds nationwide.
There was no evidence it has been set up.
Widower Michael Kivlehan and his son were awarded almost one million euro last year after the Health Service Executive (HSE) apologised for shortcomings in her care.
Dior turned four just over a week ago.
A jury of five men and two women have heard several days of detailed medical evidence on how Mrs Kivlehan died.
Although Mrs Kivlehan died in Belfast, the inquest was moved to the Republic 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 had met while living in London and had married and moved to raise a family near his family home in Dromahair, Co Leitrim.
Mr Kivlehan remained outside the inquest in Carrick-on-Shannon courthouse while detailed aspects of his late wife's care and condition in Sligo and also Belfast were read out by Dr Boylan.
The consultant said he was appearing at the inquest as an independent expert following an invitation by coroner Eamonn MacGowan.
Dr Boylan said he made his findings on the deficiencies in Mrs Kivlehan's care as an addendum to a statement already made in advance of the inquest and after reading medical notes, statements of other witnesses and press reports of last week's hearings.
The inquest heard Mrs Kivlehan was 10 days overdue when she arrived at Sligo hospital.
She had been booked to be induced on September 22 - the day after the C-section, classed by the doctors as there being an immediate risk to the mother's life.
Dr Boylan told the inquest the emergency delivery could have been carried out 12 hours earlier than it was - 5.55am on September 21 - but that it was the correct course of action.
He disagreed with the category one assessment made by medics in Sligo that Mrs Kivlehan would have died without a C-section.
"I don't think that she was at immediate danger of life," he said.
Dr Boylan said if Mrs Kivlehan had been in the care of the National Maternity Hospital at Holles Street in Dublin she would have been transferred within 24 hours of the C-section.
None of Ireland's maternity hospitals have intensive care units but they do high dependency units, the inquest heard.
Dr Boylan said it was a luxury that Holles St has access to the ICU in St Vincent's and doctors can seeking specialist advice.
"We are in the lucky position that we would have transferred her the next day," Dr Boylan said.
"We would certainly transfer very early but we have the luxury of doing that, which is not the case around the country."
Dr Boylan said it was unacceptable that a renal specialist did not see Mrs Kivlehan until 2.45pm on September 24, the day she was airlifted to Belfast.
"I think she should have had specialist input certainly from after the time she delivered on the 21st - that's the time to initiate specialist input," he said.
Dr Boylan said an investigation into why the first set of blood tests were not reviewed for 12 hours and whether a single doctor was responsible was "another day's work".
He said Mrs Kivlehan was not displaying the classic signs of pre-eclampsia or Hellp immediately before or after the C-section, but that it could have been classed as the medical term Partial Hellp.
Dr Boylan said it was his opinion that doctors in Sligo had misinterpreted her condition as she suffered from abdominal bleeding following the delivery on top of her kidney and liver problems.
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.
Dr Boylan said it was hard to say if an earlier transfer would have made a difference.
"There isn't the volume or the number of specialists or the appropriate skills available on the ground (in Sligo)," he said.
"It's better to transfer to a tertiary centre where numerous specialists are available to give appropriate care.
"Unfortunately if she had have been transferred earlier it might have made a difference but it's hard to say."
Dr Boylan criticised the medical team 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."
Dr Boylan said bleeding from the inferior epigastric artery is a well-recognised complication from a C-section. He said this was not a deficiency in her care.