The death of Dhara Kivlehan – from multi-organ failure – was due to medical misadventure, a jury unanimously decided on Monday night.
Ms Kivlehan (29), who lived with her husband Michael in Dromahair, Co Leitrim, died in Belfast’s Royal Victoria Hospital on September 28th, 2010, a week after giving birth at Sligo Regional Hospital. She had been airlifted from the Sligo hospital four days earlier.
During the five-day inquest at the Coroner’s Court in Carrick-on-Shannon, Mr Kivlehan said that when he saw Dhara hours after their son Dior was born, her body was swollen and her skin was orange and yellow. A consultant told him that she would be “fine”.
Michael Kivlehan last night appealed to other fathers not to be afraid to challenge doctors. "I would like to get the message out there to lay people that childbirth is not always that simple," he said. "And to tell the fathers they need to be more supportive of their women, especially if they have any concerns, and to have the strength to challenge doctors."
Referring to his experience of some staff in Sligo, he said medics should improve their bedside manner.
Earlier yesterday, leading obstetrician Peter Boylan told the jury that a number of deficiencies contributed to Ms Kivlehan’s death.
He said it was impossible to know if Dhara would have survived had she been transferred earlier to a specialist centre, but that would have constituted the “best possible care”.
A delay in referring the new mother to both kidney and liver specialists were contributing factors in her death, the former master of Holles Street Maternity Hospital said. He said the failure to organise any liver consult in Sligo regional hospital was “unacceptable”.
Dr Boylan cited the failure to consider the possibility of internal bleeding, the lack of intensive care beds at tertiary hospitals in Dublin and Galway, and the insufficient numbers of obstetric consultants in Sligo hospital as “material contributors” to Ms Kivlehan’s death.
Delays
If Ms Kivlehan had been transferred earlier to a tertiary centre it might have made a difference to the outcome, Dr Boylan said. It was impossible to say if she would have recovered. Under cross-examination he told Adrienne Egan SC for the HSE that it would have been better “but none of us can predict the outcome”.
Everyone was entitled to the best possible care “and the best available care was in a tertiary centre, especially St Vincent’s University hospital in Dublin”.
Dr Boylan agreed with Damien Tansey, solicitor for the Kivlehan family, that he would have transferred the young mother after delivery. Mr Tansey suggested that Dhara might never have been transferred if her husband Michael had not “put his foot down when he saw his wife disappearing before his eyes”.
The consultant also agreed that a delay in acting on blood results taken when Dhara was admitted to the hospital on September 20th was “certainly a deficiency in care”. The inquest heard the results showing acute liver and kidney dysfunction were not accessed for 12 hours.
Photographs of family
Ms Egan told the jury that this was one of the shortcomings the HSE had apologised for last December. Mr Kivlehan was awarded €800,000 in a High Court settlement.
Poignantly, 35-year-old Mr Kivlehan carried a montage of photographs of Dhara yesterday, including one of the couple with their newborn son taken in Sligo hospital. While Sunday was the fourth anniversary of Dhara’s death, he said today was the real anniversary as far as he was concerned. “Tuesday was the day they switched off the machine,” he said.
The jury last night recommended that all blood tests should be followed up by the doctor who ordered them, and that any critical issues be flagged by laboratory staff.
After just under an hour deliberating, the jury of five men and two women also recommended that a database of all available critical care beds be made known to all hospitals.
After the verdict, coroner Eamon MacGowan wished the Kivlehan family peace: “Michael has vindicated Dhara’s life and explained it through his campaign to have this inquest heard. I am sorry it has taken four years to do so.”
