The jury in the inquest into the death of Dhara Kivlehan have returned a verdict of death by medical misadventure accompanied by four recommendations.

Dhara Kivlehan died of multiple organ failure due to HELLP syndrome in September 2010 in Belfast’s Victoria Hospital, a week after an emergency caesarean section in Sligo General.

After six days of detailed evidence before Sligo Leitrim Coroner’s Court, the five men and two women deliberated over the case for less than an hour.

Their recommendations include the implementation of a flagging system for urgent blood test results; a live information database on the availability of ICU beds across the country; mandatory levels of six staff and six beds in ICUs and that all consultants involved in surgical procedures record their presence on theatre charts.

Speaking to Shannonside Radio, solicitor for the Kivlehan Family Roger Murray welcomed the verdict: