Inquests of mother and baby return medical misadventure verdict and narrative verdict

Lethal range of anti-psychotic medication found in baby's system

34-year-old paediatric nurse Nicola Keane and her husband Darren Coleman. Ms Keane and her seven-month-old baby Henry were found dead in their home on October 22, 2020. File picture: Colin Keegan/Collins

The jury in the inquests of a mother and child who died tragically have returned verdicts of medical misadventure and a narrative verdict.

The case involved paediatric nurse Nicola Keane, aged 34, whose body was discovered at Lower Rd Strawberry Beds in west Dublin on October 22, 2020, at 3.45am.

When gardaí called to her home in Lucan, Co Dublin, to inform her husband of her death, Darren Coleman, who had been asleep, found his son dead in the back bedroom.

Separate verdicts 

Although the hearings were held together, the jury returned separate verdicts.

The jury found the cause of Ms Keane’s death was polytrauma due to a fall from a height and returned a majority verdict of medical misadventure.

The cause of death for seven-month-old baby Henry was olanzapine toxicity associated with ingestion of lorazepam. 

The jury found the baby was not prescribed this medication and reached a unanimous narrative verdict.

Post-natal depression

Over the two-day hearing, several clinicians told Dublin District Coroner’s Court that Ms Keane had been receiving treatment for severe post-natal depression.

She was described as having “fixed false delusions” and her husband said he was told by medics, “don’t leave Henry alone with Nicola”.

Ms Keane expressed fears to doctors in Crumlin Children’s Hospital and was worried she “might do something” because her baby was persistently crying.

She was referred to psychiatric services in Ballyfermot in west Dublin and Dr Elena Perez said she had shown some signs of improvement before her death.

Nicola: No alcohol or drugs

In her evidence on Tuesday, Margot Bolster, the assistant State pathologist, said Ms Keane died from polytrauma due to a fall from a height and that her death was “instantaneous”.

She said toxicology tests showed no trace of alcohol or drugs in her system and that “she hadn’t taken her medication for a period of time”.

Dr Bolster also carried out an autopsy on baby Henry on October 22, 2020, at Crumlin Children’s Hospital. She said the child had “no injuries” and that “no cause of death could be determined” during the autopsy.

'Lethal' drugs in baby's system 

However, a toxicology report the following September showed a mixture of two separate medications in the baby’s system.

Dr Bolster said olanzapine, an anti-psychotic medication, in a “lethal range” was found and lorazepam which is used to treat anxiety. When asked if this was a lethal dose for a child she replied: “No, lethal for an adult.”

Inspector Brian Hanley from Lucan Garda station said an investigation was launched following the deaths and 46 statements were taken.

In his evidence, he said Ms Keane’s grey Ford Fiesta was captured on CCTV at 2.44am leaving their home and driving on the M50. Her body was later recovered by emergency services.

Mr Coleman discovered a text sent from his wife from her phone at 3.12am on the night she died.

Late-night text message

Insp Hanley said the investigation later found that most of the text was created in the notes section on Ms Keane’s phone on September 10, 2020, at 1.08pm.

Coroner Cróna Gallagher read some of the text which said Ms Keane was of the view her son was “beyond being fixed”.

She said, Ms Keane wrote: "He deserves better but it’s too late it’s not fair to keep him like this there is no future for him there is none for me I can’t see him suffer anymore".

Mr Coleman attended several psychiatric appointments with his wife and said, "at no stage was I ever asked for my opinion".

Ms Keane struggled with the baby following his birth in February 2020 and said she had no bond with him.

Nicola 'not asked about suicide'

Dr Elena Perez told the court "each patient differs" and "she wasn’t back to herself, but she was responding to it [the medication]".

In his second day of evidence, Mr Coleman said: "For the six contact sessions with Nicola before I went back to work, three home visits and three phone calls, Nicola was never asked about having suicidal thoughts or asked about harming Henry".

He continued "If I was informed, I would have taken immediate leave and taken the necessary but difficult steps in committing my wife to help her and safeguard my baby Henry".

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.

If I had been told even one piece of the information been withheld from me, I believe Henry and Nicola would not have died on October 22.

There were two recommendations made by the jury, including the building of a postnatal depression programme into the prenatal course for both parents, and if not already available, planned mother and baby inpatient units should be created.

The jury also expressed their sympathy with the family saying, "it is not the natural order to be burying your child".

Solicitors for Children’s Health Ireland and the HSE expressed their sincere condolences, while the coroner said the case has "has deeply affected everybody involved in this tragedy" and offered her deepest condolences.

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