A man whose wife and four-day-old baby boy died in a maternity hospital has pleaded with the HSE to “do the right thing” and allow a review into their tragic deaths be admitted as evidence at their inquests.
Kieran Downey said he wants to ensure that the HSE learns “from the terrible cascade of events” which led to the death of his wife, Marie, and four-day-old baby boy, Darragh, at Cork University Maternity Hospital (CUMH) over two years ago.
Speaking at Cork City Coroner’s Court, Mr Downey said he believes that the admission into the public inquest process of the independent review commissioned by CUMH into the care afforded to his wife and baby boy is the only way to ensure that the enquiry is open and transparent.
Ms Downey, 36, from Knockanevin near Kildorrery in north Cork, had a history of epilepsy and gave birth at CUMH to baby Darragh on March 22, 2019.
But at around 8am on Monday, March 25, 2019, she was found unresponsive and lying partly out of her hospital bed, with baby Darragh lying underneath her in critical condition.
Despite immediate medical attention, she could not be revived and was pronounced dead. And despite the best efforts of medics, Darragh died the following day.
It was believed that Ms Downey may have suffered a seizure while breastfeeding Darragh.
The inquests into their deaths was opened and adjourned last month following in-camera legal submissions, after which Cork City coroner, Philip Comyn ruled as inadmissible the systems analysis review report into the deaths, commissioned by Professor John Higgins, clinical director of CUMH.
The inquests were in for mention to set a full date for hearing.
Mr Downey’s junior counsel, Doireann O’Mahony, called formally on the HSE to agree to the admission into evidence of the review, its findings and recommendations.
“We are told that the report has been accepted in full, and that all 11 of its recommendations are to be implemented,” she said.
“We see no reason whatsoever then why the HSE should not honour its commitment to open disclosure, and consent to the report forming part of the documentation at the hearing.
“For an organisation that invokes “patient-centered care” as a mantra, the HSE would seem awfully careless about the lives of the two people at the centre of this enquiry if it were to insist on withholding the report.
“Furthermore, for a hospital that says that it “strives for clinical excellence”, CUMH would seem startlingly averse to public scrutiny, and learning from its mistakes, if it were to insist on keeping the report shrouded in secrecy.
“It is Mr Downey’s express request that the HSE do the right thing now, and agree to the admission of the report between now and the date of the hearing.”
Solicitor for the HSE, Eamon Harrington, rejected suggestions that the report is “shrouded in secrecy” and said the learnings had been shared with the Downey family. He also said the HSE was just one party mentioned in the report and that the difficulty was with the report being submitted as “evidence” in an inquest.
Mr Comyn said he has already ruled on the inadmissibility of the report and will not be revisiting that matter.
But he said he fully appreciates and understands the concerns of Mr Downey and his family and said he aims to secure a suitable venue for the full hearing of the inquests over three days in mid-November.
The review was chaired by Prof Norman Delanty, consultant neurologist at Beaumont Hospital Dublin, and its recommendations were accepted by Prof Higgins last July.
Among its 11 recommendations were the immediate appointment of a specialist epilepsy nurse to the hub maternity hospital in each of Ireland’s hospital groups, the appointment of a consultant neurologist with an interest in maternity health at Cork University Hospital (CUH), and that consideration be given to the provision of new seizure warning devices in individual circumstances in maternity hospitals.