The jury at the inquest into the death of Dhara Kivlehan has returned a unanimous verdict of medical misadventure.Ms Kivlehan died in Belfast in 2010 as a result of multi-organ failure, days after giving birth at Sligo General Hospital.

The jury of five men and two women debated for just under an hour. The legal team representing the Kivlehan family had asked the five men and two women on the jury to endorse a number of recommendations including a prompt fail-safe method of following up on blood tests and the implementation of a national database to highlight the availability of ICU beds around the country.

Ms Kivlehan’s husband, Michael, said he hoped lessons have been learned by healthcare professionals as a result of this inquest. The Health Service Executive has apologised in full to the Kivlehan family.

Earlier, the former master of the National Maternity Hospital in Holles Street told the inquest that there were deficiencies both in the clinical care of Dhara Kivelhan and at a systemic level. Dr Peter Boylan said the outcome might have been different if the patient’s internal bleeding had been recognised and dealt with earlier. However, Dr Boylan said it was debatable whether early intervention would have made a significant difference given the extremely complicated nature of her condition.

Dr Boylan was attending the final day of the inquest as an expert witness. He said Ms Kivlehan had developed partial HELLP Syndrome – a severe strain of pre-eclampsia.Her condition was complicated by acute liver and kidney dysfunction. Dr Boylan said she remained seriously ill following the delivery of her baby by emergency Caesarean section. He said blood loss does not appear to have been seriously considered as a complication of her surgery.

Dr Boylan said Ms Kivlehan presented a very difficult management problem, but he said her distended stomach was misinterpreted as fluid build-up linked to liver failure.

It appears, he said, nobody considered the likelihood of what he called intra-abdominal bleeding, particularly following her surgery. This was most likely in a post-operative woman whose haemoglobin had dropped significantly. Dr Boylan said had this problem been recognised and dealt with, and an earlier transfer organised to a specialist centre, then it is possible the outcome would have been different. However, he said, this remains conjecture.

Ms Kivlehan was transferred by helicopter to the Royal Victoria Hospital in Belfast. She died four days later. Dr Boylan insisted lack of continuity of consultant care was an issue in this country. He said Sligo was no different than any other hospital and he stressed he was not blaming the doctors.Dr Boylan said consultants are thin on the ground in Ireland and that a woman as ill as Dhara Kivlehen should be under a senior obstetrics consultant. Dr Boylan added that she was probably in the wrong place in the first instance and should have been transferred earlier to a specialist centre – ideally St Vincent’s Hospital in Dublin.

Dhara Kilvelan inquest: