PATIENTS in regional hospitals who become critically ill face a 'lottery' on whether or not they get specialist treatment, despite recommendations made to the HSE four years ago.
The Herald has obtained a copy of a 'Serious Incident Review' which was written within three weeks of the death of mum Dhara Kivlehan in September 2010.
An inquest this week found the 28-year-old had died as a result of medical misadventure at Sligo Regional Hospital.
She passed away in a Belfast hospital, nine days after giving birth to her son Dior.
Dhara was already suffering from multiple organ failure when she was flown by helicopter to the Royal Victoria Hospital because specialist care beds weren't available in Dublin or Galway.
Now a HSE whistleblower says the organisation was aware four years ago that a review recommendation that a 'real-time' bed availability system should be set up to prevent delays in the care of critically ill patients.
However, the system has still not been set up four years after Dhara's death and doctors in regional hospitals still have to call tertiary hospitals elsewhere when critical care is needed.
The Serious Incident Review had just one recommendation and it reads: "A system whereby the number and location of vacant critical care beds can be made known to all hospitals regionally and nationally should be developed."
The HSE whistleblower warned that more lives will be lost unless the system is brought in.
"We have the crazy situation of consultants or doctors in hospitals having to ring around other hospitals to check to see if beds are free," said the source.
"It is an antiquated system to say the least and that doesn't even take into consideration the time and anxiety caused to medical staff desperately trying to get critical care for someone who is seriously ill.
"In some cases where helicopter transport is needed, the faster doctors know the destination hospital, the faster that transport can be organised.
"It is a disgrace that the HSE still hasn't got its act together despite this warning after the death of Dhara Kivlehan.
"Basically, we are in a situation here where critical care beds are almost always in Dublin, Cork or Galway but if your nearest hospital isn't in those locations you could lose your life."
The Serious Incident Review found that attempts to get a bed for Dhara at St Vincent's or in Galway failed and that is why a decision was taken to send her to Belfast.
The Kivlehan's solicitor, Roger Murray told the Herald: "At the inquest the independent expert Dr Peter Boylan found seven clinical failures in Dhara's care. This internal review found just one, and that there was no system for monitoring the availability of critical care beds in tertiary hospitals.
"The Kivlehan family is concerned that the one recommendation of the hospital's own review has never been implemented.
"We found a memo during the case which showed this issue was under review but had not been pursued due to lack of resources. It is unacceptable that something so simple but potentially life-saving has been left to gather dust on a shelf."
The HSE did not respond to request for comment last night.