Medical misadventure verdicts at inquest into deaths of woman and baby

Medical misadventure verdicts have been returned by a jury at an inquest into the deaths of a mother and her newborn son at Cork University Maternity Hospital (CUMH) in 2019.

Marie Downey (36) had an epileptic seizure in her hospital bed and collapsed on top of four-day-old Darragh. The weight of her body stopped the blood supply to his brain and other organs and he died 33 hours later despite major medical intervention, Cork Coroner’s Court heard.

Mrs Downey, a mother of three from Knockanevin, Kildorrery, was dead when hospital staff found her and Darragh in a private room in the hospital shortly after 8am on March 25th, 2019.

Dr Peter Kelehan, a retired paediatric pathologist who carried out a postmortem on Darragh, told the court the infant would have needed to have been found within five minutes of his mother falling on him to stand any chance of survival. He said Darragh suffered acute respiratory failure and necrosis of numerous organs, particularly the heart and brain, as well as a reperfusion injury.

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Assistant State Pathologist Dr Margaret Bolster, who carried out a postmortem on Mrs Downey, said she suffered an upper cervical spinal cord injury which caused cardiac arrhythmia. She said the fall occurred because of an epileptic seizure and the neck injury was the immediate cause of death.

“She [Marie] wouldn’t have known a thing. It would have been an instant blackout,” Dr Bolster told the Downey family’s senior counsel, Dr John O’Mahony, describing their deaths as “an enormous tragedy”.

Doireann O’Mahony, junior counsel for the family, said it had been a “difficult few days” for all involved in the case, but mostly for Mrs Downey and Darragh’s loved ones.

She said Mrs Downey was under the care of obstetrician Dr Keelin O’Donoghue and that there was no plan of care in place for her pregnancy as a mother with epilepsy.

“No attempt was made by the hospital to monitor the levels of Lamictal [anti-convulsant medication] in her blood. Marie suffered a major post-partum haemorrhage and spent the night in a high dependency unit,” she said.

“In spite of the clear risk factor for seizures and in spite of her known and stated morbid fear and paranoia that she would have a seizure while breastfeeding, she was taken from the high dependency unit and placed in a single room.”

‘Regrettable oversight’

The inquest heard that during Mrs Downey’s third pregnancy, with Darragh, Dr O’Donoghue did not write to her patient’s neurologist about her care. Dr O’Donoghue apologised for a regrettable oversight.

Ms O’Mahony stated apologies were cases of “too little, too late” and that the family had waited for a considerable amount of time for the inquest to be heard.

“Every death is a tragedy and there is no hierarchy of tragedies when it comes to grief. But having known this family and what they have been through, it ranks as the most horrific of fatal injury cases I have seen or inquests I have ever dealt with.”

She said Mrs Downey was an only child and much loved by her husband, Kieran, sons Seán and James, and wider family.

Conor Halpin, SC, for the HSE, said his side would not be offering any submission against a verdict of medical misadventure in the case. He offered his heartfelt condolences to the family on their loss, as did Oonagh McCrann SC for Dr O’Donoghue and Sgt Fergus Twomey on behalf of An Garda Síochána.

Dr O’Mahony said the inquest would stand out in the “annals of history” in relation to the care of pregnant women. He thanked the coroner and the jury for their assistance.

Cork city coroner Philip Comyn commended the jury for their “attention to detail” and said it was the first double tragedy he had dealt with in his career and that he hoped it was the last.

The jury made a series of recommendations in the case including that an independent systems review report into the case be implemented.

Since the tragedy occurred, HSE guidance on women with epilepsy has been widely circulated to all maternity units. Medications for co-morbidities when taken by inpatients must be prescribed and the administration of medication must be documented in the patient’s healthcare record.