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.
An inquest into her death at Carrick-on-Shannon courthouse over five days has heard of a number of delays and deficiencies in her care at Sligo.
There was a 96-hour wait from her admission on September 20 for much-needed assessments by a kidney specialist, while the first blood tests were not reviewed for 12 hours, the jury have been told.
Doctors have said she was suffering liver and kidney injury on that day.
Mrs Kivlehan gave birth to a son, Dior, at 6am the following day.
Coroner Eamonn MacGowan told the jury of five men and two women they had only two options for verdicts.
He said the narrative would consider that Mrs Kivlehan died from multi-organ failure and had suffered from Hellp syndrome — haemolysis, elevated liver enzymes and low platelets, a severe strain of pre-eclampsia.
The coroner said it could include a reference to the delays in her blood tests being reviewed and the failure to carry out a CT scan in Sligo or to arrange a transfer to an intensive care unit or tertiary care centre.
Mr MacGowan said the other possible verdict of misadventure involved an unintended outcome of an intended action in a medical context.
“I want you to consider two possible verdicts,” he said. “One is a narrative which describes in general terms what the deceased died from and perhaps matters that caused that.
“The other is death by misadventure which bears no connotation of censure in this case to Sligo General Hospital.”
Mr MacGowan directed the jury to return a unanimous verdict and also gave them the option of bringing in a ryder or recommendation in the interests of improving safety in healthcare.
He discussed a number of suggested recommendations, offered previously by the Kivlehans’ lawyers.
They include a new blood test review system to avoid delays, a referral system for tertiary care and the implementation of a planned national database on the number and location of intensive care beds at Irish hospitals.
‘We wanted answers about how Dhara died’
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 Snr, 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 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 €1m 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.
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.
Coroner Eamonn MacGowan told the jury they had only two options for verdicts.
He said the narrative would consider that Mrs Kivlehan died from multi-organ failure and had suffered Hellp syndrome.
The other possible verdict of misadventure involved an unintended outcome of an intended action in a medical context.