Deaths of mother and baby could have been avoided, inquests hear

Jury reaches verdict of medical misadventure in Nicola Keane’s death and narrative verdict in son’s

The deaths of a mother and her baby boy could have been avoided if the concerns of medical staff about her mental health had been shared with her husband, an inquest has heard.

Darren Coleman, husband of Nicola Keane, told a sitting of Dublin District Coroner’s Court that he had endured a three-year wait as “the only member of my family alive to speak” to voice his concerns.

Mr Coleman said he was concerned about the care his wife had received for postnatal depression and the lack of information he was given by her doctors about her condition.

Ms Keane, a 34-year-old paediatric nurse from Ballina, Co Mayo, was found dead under the M50 Westlink bridge in the early hours of October 22nd, 2020.


When Mr Coleman was woken a short time later by gardaí who called to the couple’s home at Shackleton Way, Lucan, Co Dublin, he discovered their seven-month-old son, Henry, in an unresponsive state in a spare bedroom.

The baby boy was pronounced dead shortly after being brought to Children’s Health Ireland at Crumlin.

A jury of six women and one man returned a majority 6-1 verdict of medical misadventure in relation to Ms Keane’s death.

The jury separately returned a unanimous narrative verdict in relation to baby Henry who they said had died from ingesting drugs which he had not been prescribed.

The jurors recommended that a postnatal depression programme should be built into antenatal courses for both parents.

They also recommended the provision of mother and baby in-patient units in hospitals, if they were not already available.

Evidence was heard earlier that Ms Keane told doctors that she was concerned that she might “do something” because of her son’s irritability and her fears they were not bonding, although she repeatedly denied any intention of suicide or harming her son.

On the second day of the inquest on Tuesday, Mr Coleman told the coroner, Cróna Gallagher, that he had placed “complete and utter” trust in the professionals treating his wife.

He said it must have broken his wife’s heart when doctors told the couple that he should not leave her alone with their son.

Mr Coleman believed he should have been informed that his wife’s medication had been increased twice around a month before her death as well as about any possible side effects and that doctors had noted that she had “delusional beliefs and depressive episodes.”

“To read about this after their deaths has hurt me so much that I will never recover from it,” said Mr Coleman.

The inquest heard Ms Keane had also gone almost two months without a clinical assessment shortly before her death.

Mr Coleman told the inquest that there were 12 days when his wife received no communication from her care team.

He believed he should have been informed that she had not answered her phone on three occasions during this period.

“If I had been told even one piece of the information being withheld from me, I believe Henry and Nicola would not have died,” he added.

He pointed out that his wife was never asked during six meetings with medical carers before he returned to work if she had any suicidal thoughts or intention of harming their son.

A paediatric psychologist at CHI Crumlin, Aoife Twohig, told the inquest that she had arranged an urgent psychiatric review of Ms Keane in July 2020 because of her concerns about Ms Keane’s mental health.

In other evidence, Ms Keane’s psychiatrist Elena Pérez said she assessed the risk with Ms Keane on the last occasion she saw her about a fortnight before her death as “extremely low” as she was improving.

Asked by Dr Gallagher if it was possible that increasing Ms Keane’s dosage of an antidepressant with serious side effects had increased the risk of suicide or harming her son, Dr Perez replied: “I don’t think so.”

Assistant State Pathologist, Margot Bolster, said a postmortem showed that Ms Keane suffered multiple fractures which were injuries consistent with a fall from a height, while death would have been instantaneous.

Dr Bolster said alcohol and drugs had played no role in her death.

The pathologist said the lack of drugs in Ms Keane’s body meant she had not taken her prescribed medication for up to 20 hours before her death.

Dr Bolster said an autopsy on the baby revealed he had a lethal level for adults of an antipsychotic drug (that had been prescribed for Ms Keane) which in combination with a sedative had caused his death.

She said it was impossible to say if the baby had been given an intentional overdose.

At the conclusion of the inquest solicitor for the HSE and CHI Crumlin, Simon Mills SC, said a number of verdicts were possible but not medical misadventure as suggested by counsel for Mr Coleman, Sara Antoniotti SC.

At the conclusion, solicitor for the HSE and CHI Crumlin, David Hickey, expressed sincere and heartfelt condolences to the Coleman and Keane families.

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