A heartbroken husband whose wife died 10 days after being admitted to hospital pregnant with their first child spoke last night of his relief that his four-year fight for justice is over.
An inquest jury at Carrick-on-Shannon court returned a verdict of death by medical misadventure in the case of Dhara Kivlehan (28).
She died in a Belfast hospital on September 28, 2010. She gave birth to their son Dior on September 21 in Sligo but her condition deteriorated over the following few days.
The jury found that Dhara had died as a result of multiple organ failure and from HELLP syndrome, a severe form of pre-eclampsia.
After 58 minutes of deliberations, they found that Dhara, a retail manager with the British fashion retailer Next, had died as a result of medical misadventure.
Mr Kivlehan had originally had a request for an inquest refused because his wife had died in the North, a decision reversed earlier this year.
"I'm relieved it's over," said Michael afterwards. "It has taken four years to get to this stage. It was my boy's birthday last week and my wife's anniversary on Sunday.
"I carry pictures of Dhara with me everywhere, pictures of her as a child in India, pictures from our wedding day and one picture of her holding Dior after he was born."
Dhara, originally from Ahmedabad in the west Indian province of Gujarat, met Leitrim native Michael in London. He speaks to her mother, father, brother and sister via Skype each day.
"They are very private people but understand what went on and are amazed that Dhara died," he said. "They cannot understand why she died. I want lessons to be learned from this; no mother should die giving birth in this country.
"The case is over now but the message should go out to fathers out there not to assume everything is going to be all right. You must speak out and you must take care and make sure that if your wife is pregnant they are getting the best care in our hospitals," he added.
Dr McGowan gave the jury the options of two possible verdicts after lengthy legal arguments, one of 'medical misadventure' and a narrative verdict setting out the circumstances of Dhara's death.
The jury added 'riders' or recommendations that information on the availability of tertiary beds be made available on a national basis to all hospitals and an onus on doctors to follow up on all blood tests. They also recommended that all medics in an operating theatre should be included on a register and recommended that staffing levels in hospitals should be monitored.
Earlier, Adrienne Egan, counsel for the HSE, had argued in the absence of the jury that a verdict of death by natural causes should have been an option for the jury.
However, Dr McGowan refused to include a 'natural causes' option in the verdicts.
After the case was over, Dr McGowan said Michael Kivlehan had done right by his wife by being able to find out for his son how his mother had died.
"I wish them peace, tranquility and contentment into the future," said the coroner who said he was sorry it took four years for the case to be heard.
The jury spent yesterday listening to the country's leading expert on maternity care who said that Dhara's death was a result of deficiencies in her care and she may well have survived had doctors acted differently.
The clinical director of the National Maternity Hospital in Dublin, Dr Peter Boylan, told the inquest: "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, when she was suffering from other medical problems.
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 deficiency in clinical care was the delay in transferring Dhara from Sligo Regional 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."