Updated 9.27pm
THE JURY IN the inquest into the death of 29-year-old Dhara Kivlehan has returned a unanimous verdict of medical misadventure accompanied by four recommendations.
Dhara Kivlehan died of multiple organ failure due to HELLP syndrome in September 2010 in Belfast’s Victoria Hospital, a week after an emergency caesarean section in Sligo General.
After six days of detailed evidence before Sligo Leitrim Coroner’s Court, the five men and two women deliberated over the case for less than an hour.
They had been asked to consider two possible verdicts - one of medical misadventure – which involves an unintended outcome of an intended action in a medical context. The other was a possible narrative verdict that Ms Kivlehan died of multiple organ failure following a delay in accessing blood results; failure to undertake a CT Scan, failure to admit the patient to ICU and failure to transfer her to a tertiary centre.
Solicitors for the Kivlehan family had urged the jury to make recommendations that include among others a failsafe mechanism be put in place for the review of blood test results and a system to identify the location and availability of critical care beds right around the country.
The jury recommendations include the implementation of a flagging system for urgent blood test results; a live information database on the availability of ICU beds across the country; mandatory levels of six staff and six beds in ICUs and that all consultants involved in surgical procedures record their presence on theatre charts.
Earlier today, the country’s leading maternity expert has described the case of Dhara Kivlehan as a broad “consequence” of Ireland’s lack of consultant obstetricians.
In evidence on the final day of the inquest into the death of the 29 year old, Dr Peter Boylan says it’s well recognised that Ireland has the lowest number of consultants per head of population in the OECD, Shannonside’s Denise Canavan reports.
The former Master of Holles St Hospital has hit out at the lack of continuity of care at senior consultant level afforded to Dhara Kivlehan the week before her death in September 2010, in Sligo General Hospital.
Dr Peter Boylan says his point is not a criticism of the senior consultants involved, because it’s simply the situation they find themselves working in – that there is an insufficient number of obstetric consultants on staff at Sligo General Hospital.
Dr Boylan pointed to the fact that Dr Raoud Sallam had to leave the hospital to attend a clinic the day after Dhara Kivlehan’s emergency c-section and that the majority of notes taken in the case were recorded by the registrar on duty Dr Hind Al Husain.
The clinical director of the national maternity hospital says a woman so sick would be better treated if there was continuity of care by the senior obstetric consultant involved.
He added that most registrars are working in training positions and that he is aware that there is an issue with resources nationwide – saying consultants are “thin on the ground” and that Sligo is no different to any other hospital in this regard.
He said there is a need for a much more hands on involvement by senior consultants in cases as serious as this, but added that whether this would have made any difference to the outcome is “debateable” given that Dhara Kivlehan was “probably still in the wrong place” having not been already transferred out of Sligo General hospital.
Reporting by Denise Canavan. Published with permission of Shannonside, Longford, Roscommon and South Leitrim radio. See more at their website and follow them on Twitter @ShannonsideNews and @DeniseCanavan.
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