Despite the HSE's pleas to obscure the verdict at the inquest into the death of Dhara Kivlehan, the jury unanimously found her death was a result of medical misadventure.
Surely Michael Kivlehan has had enough suffering. He lost his dearly-loved, 28-year-old wife Dhara, who died days after giving birth to their son, Dior, in a maternity ward in Sligo Regional Hospital, in September 2010. Yet it took three years of legal wrangling for the HSE to 'unreservedly' apologise for the 'shortcomings' in her care and pay out €790,000 in compensation.
Dhara Kivlehan actually died in a Belfast hospital, where she was transferred four days before she died. But, there were three critical days between giving birth and being transferred from Sligo hospital, where Dhara's health deteriorated rapidly. Her husband Michael wanted to find out why.
Despite apologising for the poor care she received, and admitting liability by paying out over three quarters of a million euro to the Kivlehan family last year, the HSE added insult to injury at the inquest, when their senior counsel, Adrienne Egan, argued that the jury be given the option of 'natural causes'.
The HSE's legal team then tried to persuade the coroner to stop any reporting of the fact that they sought a possible 'natural causes' verdict. There was absolutely nothing natural about the death of Dhara Kivlehan.
In his wisdom, the coroner overruled these requests. The jury took less than an hour to reach their verdict of 'medical misadventure' and the coroner allowed reporting of the case.
Dhara Kivlehan had a very serious condition called Hellp syndrome, which occurs in 10pc of all cases of extreme or full-blown pre-eclampsia. The death rate for women with Hellp is less than 1pc. In most cases, medical intervention saves women's lives.
The Clinical Director of the National Maternity Hospital, Dr Peter Boylan, was an independent expert witness at the inquest. He identified four clinical failings in the care that Dhara Kivlehan received in Sligo Regional Hospital.
Critical blood test results were available the afternoon she was admitted to Sligo hospital but were not followed up on. Only when the results were read by a midwife on her ward at three o'clock the next morning was the urgency of her situation realised.
They immediately proceeded with an emergency c-section. Her healthy baby boy was born but despite recognising she would need Intensive Care after the emergency surgery, there was a 36-hour delay in getting her a bed in the ICU. This resulted in critical delays in specialist care.
A serious incident report was subsequently written about the case locally in October 2010, yet staff central to her care were not even interviewed for this report.
Dr Boylan also identified three systemic failings including the shortage of consultants and ICU beds as contributing to the rapidly deteriorating condition of Mrs Kivlehan.
There has been an increase of eight consultant gynaecologists and obstetricians (from 125 to 133) since 2010 but, as Dr Boylan pointed out, the shortage of sufficient consultants on-site meant there was no continuity in Mrs Kivlehan's care. No one expects that all specialities are available in all 19 maternity units in Ireland, but it is reasonable to expect these 19 units know enough to know when it is appropriate to refer women to another hospital.
This shortage of specialist care on-site, combined with the local and national shortage of ICU beds, meant Mrs Kivlehan did not get the specialised treatment she needed at the earliest opportunity.
And things have only got worse since. There are now 28pc fewer ICU beds than there were in 2009, despite growing need.
In November 2013, the HSE and the State Claims Agency launched a new open disclosure policy. Under this new policy, the HSE state that they want their 'services to support an open, timely and consistent approach to communicating with service users and their families when things go wrong in healthcare'.
Quite clearly, this policy was not in place nor acted upon in September 2010 in Sligo hospital when consistent queries by Michael Kivlehan were fobbed off. His attempts to find out what actually happened his wife were obfuscated by the HSE right up until the inquest verdict this week.
In the spirit of their own open disclosure policy, there is an urgent need for the HSE or HIQA to understand what exactly went wrong during Dhara Kivlehan's treatment in Sligo.
Why is it that women who go into hospital to give birth become names on newsreel in their deaths? Tania McCabe, Bimbo Onagua, Dhara Kivlehan, Savita Halappanavar, Sally Rowlette - how many more women have to die during or after receiving care in Irish maternity units for this to really be one of the safest little countries in the world to give birth in?
It is up to this Government, the Health Minister and the HSE to ensure that all women giving birth in Irish hospitals receive the highest quality of care. And that when things go wrong, that they are admitted to, acted upon, learnt from and not denied.
Sara Burke is a health policy analyst and a research fellow in Trinity College Dublin