The former master of the National Maternity Hospital in Holles Street has told an inquest into the death of Dhara Kivlehan that there were deficiencies both in her clinical care and at a systemic level.
Dr Peter Boylan said the outcome might have been different if the patient’s internal bleeding had been recognised and dealt with earlier.
However, Dr Boylan said it was debatable whether early intervention would have made a significant difference given the extremely complicated nature of her condition.
Ms Kivlehan died in Belfast in 2010 as a result of multi-organ failure, days after giving birth at Sligo General Hospital.
Dr Boylan was attending the final day of the inquest as an expert witness.
He said Ms Kivlehan had developed partial HELLP Syndrome – a severe strain of pre-eclampsia.
Her condition was complicated by acute liver and kidney dysfunction.
Dr Boylan said she remained seriously ill following the delivery of her baby by emergency Caesarean section at Sligo General Hospital in 2010.
He said blood loss does not appear to have been seriously considered as a complication of her surgery.
Dr Boylan said Ms Kivlehan presented a very difficult management problem, but he said her distended stomach was misinterpreted as fluid build-up linked to liver failure.
It appears, he said, nobody considered the likelihood of what he called intra-abdominal bleeding, particularly following her surgery.
This was most likely in a post-operative woman whose haemoglobin had dropped significantly.
Dr Boylan said had this problem been recognised and dealt with, and an earlier transfer organised to a specialist centre, then it is possible the outcome would have been different. However, he said, this remains conjecture.
Ms Kivlehan was transferred by helicopter to the Royal Victoria Hospital in Belfast. She died four days later as a result of multi-organ failure.