Dr Peter Boylan tells Kivlehan inquest of deficiencies in care

An expert witness has told the inquest into Dhara Kivlehan’s death that a delay in getting specialist renal and liver care for her was one of a number of material contributors to her death.

A verdict in the inquest is expected at the Coroner’s Court in Carrick-on-Shannon, Co Leitrim, today.

Dr Peter Boylan said it was clear to him there were deficiencies in both Ms Kivlehan's clinical care and at systemic level, which were "material contributors" to her death.

Ms Kivlehan (29), died of multi-organ failure due to HELLP syndrome, a severe form of pre-eclampsia, in Belfast's Royal Victoria Hospital on September 28th, 2010. She had been airlifted from Sligo Regional Hospital four days earlier.

Among the deficits in clinical care which the consultant obstetrician highlighted in the case were the attribution by staff at Sligo Regional Hospital of all her problems to HELLP syndrome . He told the jury she should have been referred to both a liver and renal consultant earlier.

The former master of the National Maternity Hospital said that failure to seriously consider the possibility of intra-abdominal haemorrhage in the post-operative period and delay in transfer to a tertiary centre - ideally St Vincent's University Hospital Dublin - were also factors.

The system failures which Dr Boylan highlighted were the lack of prompt availability of specialist renal and liver input at Sligo Regional Hospital .

Another factor was the lack of intensive care beds at tertiary hospitals in Dublin and Galway. Dr Boylan added that the lack of continuity of care at consultant level due to an insufficient number of obstetric consultants on staff at the Sligo hospital were also factors.

He stressed Ms Kivlehan had presented in a most unusual way with both severe liver and renal failure.

Dr Boylan said if she had been transferred to a tertiary centre in Dublin or Galway it might have made a difference, “but it is hard to say”.

He said it was an “error of judgment” that one Sligo-based consultant had queried whether her swollen abdomen was due to internal bleeding, but that this was not investigated further.

The consultant agreed with Damien Tansey, solicitor for the Kivlehan family, that a delay in acting on blood results taken when Ms Kivlehan was admitted to the hospital on September 20th was “certainly a deficiency in care”. The inquest has heard the results were not accessed for 12 hours.

Mr Boylan said he was not trying to excuse in any way the lack of keenness to source results, but wanted to explain what happened in terms of everyday life in a hospital.

Mr Tansey put it to the expert that if the blood tests had been acted on quickly, Ms Kivlehan might have had an emergency caesarean section 12 hours earlier, and then staff could have focused on her liver and kidney problems.

Dr Boylan pointed out that she showed sign s of “clonus” after being admitted, which staff interpreted as possible onset of seizures related to pre-eclampsia - but in fact this was more likely to have been linked to liver failure. He said staff were presented with “a very complex situation”.

Dr Boylan said Ms Kivlehan suffered a significant intra-abdominal bleed after her emergency caesarean section.

Her abdominal swelling was mistakenly attributed to ascites (fluid in the abdomen) , probably in association with her liver failure.

He said Ms Kivlehan presented a very “difficult management problem”, but there was undoubtedly a misinterpretation of her abdominal distension which was incorrectly not attributed to 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 added.

“Nevertheless, had this intra-abdominal haemorrhage been recognised and dealt with, and an earlier transfer to a tertiary centre organised, it is possible that the outcome might have been different. This however remains conjecture.”

The hearing continues.