Failures led to death of Dhara, inquest is told
A LACK of intensive care beds in Dublin hospitals has been identified among three systematic failures in the care of Dhara Kivlehan, who died after giving birth to her first child.
The country's leading expert on maternity care said that the 28-year-old's death was a result of deficiencies in her care and she may well have survived had doctors acted differently.
Dhara Kivlehan died in September 2010 just 10 days after giving birth to her son Dior by emergency caesarian section at Sligo General Hospital.
She died at Belfast's Royal Victoria Hospital.
At the resumed inquest into her death at Carrick-on-Shannon court house today, the Clinical Director of the National Maternity Hospital in Dublin, Dr Peter Boylan, added a note to his report on Dhara's death.
In it, he said: "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 systematic level."
He noted deficits in clinical care included the attribution of all of Dhara's medical problems to HELLP syndrome, a severe form of pre-eclampsia.
He criticised the delay in obtaining renal and liver specialist input and the failure to consider the possibility of intra-abdominal haemorrhage after the C-section. Dr Boylan said another deficit in clinical care was the delay in transferring Dhara from Sligo General to an expert centre, which he said was ideally St Vincent's University Hospital in Dublin.
The medical expert said there were three systematic failures in the care of Indian-born Dhara who died from multiple organ failure.
These included the lack of prompt availability of renal and liver specialists at Sligo, the lack of intensive care beds at tertiary hospitals in both Dublin and Galway and the "lack of continuity of care at consultant level due to insufficient numbers of obstretic consultants on staff at Sligo General Hospital."
Dr Boylan reviewed all of Dhara's medical notes and made a number of critical comments in his evidence.
In his summary of Dhara's care at Sligo General, Dr Boylan noted: "Blood loss as a complication of her surgery does not appear to have been seriously considered despite significant falls in her haemoglobin...her renal function and liver function remained significantly abnormal."
The medical expert said in his report to the jury of five men and two women: "Mrs Kivlehan presented a very difficult management problem but there was undoubtedly a misinterpretation of her abdominal distension which was incorrectly not attributed to intra-abdominal bleeding.
"It is debatable however whether or not earlier intervention to deal with this problem would have made a significant difference in the long-term given the extremely complicated nature of her presentation," he said.
"Nevertheless had this intra-abdominal haemorrhage been recognised and dealt with, and an earlier transfer to a tertiary centre been organised, it is possible the outcome might have been different.
"This however remains conjecture."
The inquest is continuing.