Audit of ICU facilities needed after Kivlehan inquest

Analysis: inquest raises questions about clinical care, writes Muiris Houston.

Dhara Kivlehan had a severe form of pre-eclampsia called Hellp syndrome, which was the direct cause of her untimely death.

Pre-eclampsia is a multi-system disorder involving the placenta, liver, kidneys and the neurological and cardiovascular systems. It is usually picked up by routine screening of blood pressure and by urinalysis: the presence of protein in a woman’s urine suggests the kidneys are under stress.

Hellp describes a group of clinical signs: “h” stands for haemolysis (the breakdown of red blood cells); “el” represents elevated liver enzymes; and “lp” stands for low platelet count. It occurs in more than 10 per cent of cases of severe pre-eclampsia or full-blown eclampsia.

Serious complications

As many as one in four women with Hellp develop serious complications, including a breakdown of the body’s clotting system called disseminated intravascular coagulation (DIC); fluid build-up in the lungs; kidney failure; liver haemorrhage; and failure and separation of the placenta from the wall of the uterus.


Treatment includes early delivery of the baby and a whole range of supportive therapies including lowering blood pressure, an infusion of platelets and respiratory support provided in an intensive care unit.

Dr Peter Boylan, an expert witness at the inquest into Ms Kivlehan's death, said it was clear to him there were deficiencies in both her clinical care and at systemic level, which were "material contributors" to her death.

Among the systemic issues that need to be addressed by the Health Service Executive in the aftermath of the inquest is whether there are sufficient intensive care beds available in the system.

It is worrying that initially Sligo Regional Hospital had no ICU bed for Ms Kivlehan while subsequently, at tertiary hospital level, neither Galway nor Dublin could provide intensive care facilities. While it is not unknown in an international context for intensive care facilities to be made available some hundreds of miles away from where the patient lives, an audit of ICU facilities in the State must now be carried out.

Another possible system failure was the lack of prompt specialist kidney and liver specialist input at Sligo Regional Hospital. Does the northwest region have a shortage of renal and liver specialists? Another question is whether there is a sufficient number of consultant obstetricians at the hospital to provide continuity of care.

Deficiency of care

In a worrying echo of the Savita Halappanavar case, a delay in accessing the results of blood tests also featured in this inquest. Although Ms Kivlehan did not have sepsis, in her case tests showing abnormal liver and kidney function and blood clotting problems were not looked at for a 12-hour period. Dr Boylan referred to this as a “deficiency of care”.

Chasing test results is not rocket science and is usually done by junior hospital doctors.

Another clinical issue highlighted by the inquest was an apparent assumption by doctors that abdominal swelling was due to liver failure rather than the result of post- Caesarean section bleeding. However, due to the complicated nature of Ms Kivlehan’s presentation, earlier surgical intervention may not have altered the outcome.

While the mortality rate of Hellp syndrome is less than 1 per cent in the western world, unfortunately Ms Kivlehan was one of a minority who have not survived this serious illness.