Widower tells Cork inquest death of wife and son could have been prevented

Mr Downey said his wife and newborn son would not have died in Cork University Maternity Hospital if there was better communication between medics
Widower tells Cork inquest death of wife and son could have been prevented

Kieran Downey, husband of the late Marie Downey, told the inquest at Cork city Coroner's Court: “These are people, our loved ones. It could be anyone’s loved ones." Photo: Cork Courts Limited

A man whose wife and newborn son died in Cork University Maternity Hospital (CUMH) said their deaths could have been prevented if guidelines were followed and there was better communication between medics involved in her care.

Kieran Downey also told Cork City Coroner Philip Comyn that he has no confidence in the HSE system after he discovered six weeks after the deaths of Marie and four-day-old Darragh Downey that their deaths had not been recorded on the hospital’s Maternity Patient Safety Statement for March 2019.

“My wife and son should have been recorded on the system. It doesn’t show any transparency. It’s a box-ticking exercise,” he said.

“These are people, our loved ones. It could be anyone’s loved ones. They were not given the respect to have the factual information presented to the public.

“If you can’t even do the basic recording of deaths, how can anyone trust the system we have.” The revelation prompted an apology during the inquest from CUMH, through senior counsel, Conor Halpin, for the omission but he said their deaths had been reported to the National Perinatal Epidemiology Centre.

Mr Downey said: "It could all have been prevented at different points along the way if there was better communication. We wouldn't be here today. How can this happen where there are guidelines for treating epileptic patients?

"There is a whole list of things that should have been done, and none, or very few were done. If they were, we'd be sitting at home without a care in the world."

Mr Downey made his comments as he gave emotional evidence on the first day of full hearings of the joint inquest into the deaths of his wife and son in March 2019.

Marie Downey's epilepsy

He said he was appalled and disgusted that he could only read two of the three statements he prepared for the coroner - statements his legal team, Dr John O'Mahony SC and Doireann O'Mahony, junior counsel, said were vital to provide the jury with all the facts.

The inquest heard that Ms Downey, 36, from Knockanevin near Kildorrery in north Cork, had epilepsy since 2010, was attending neurologist Dr Peter Kiniron for the management of her epilepsy and was very good at taking her anticonvulsant medication, lamotrigine, sold as lamictal.

“Her epilepsy never affected Marie's life, it never affected the way we lived. We were conscious of it all the time but because she had so little seizures, we weren't paranoid,” he said.

During the course of her first pregnancy in late 2013, she suffered a seizure at about 30 weeks, before giving birth to her first child in February 2014.

During her second pregnancy in 2016, she suffered a seizure in the postnatal period after which she confided in a midwife that she was fearful she would seize while breastfeeding.

“When she was breastfeeding on our first two sons, James and Sean, I would bottle feed them from time to time to let her get some rest, if she was afraid she was too tired and she knew that tiredness may cause seizures,” Mr Downey said.

“We didn't have any concern really about seizures only at the stressful times of where there would be a lack of sleep."

When she was pregnant with Darragh, Ms Downey was under the care, as a private patient, of consultant obstetrician, Dr Keelin O’Donoghue.

The birth of Darragh Downey

Shortly after she gave birth to Darragh at CUMH on Friday, March 22, 2019, Ms Downey experienced a significant postpartum haemorrhage, losing up to a fifth of her blood. Consultant anaesthesiologist, Dr Dan Mullane, said he wasn’t aware that Ms Downey had epilepsy and his initial focus was on stopping the hemorrhage and that Ms Downey responded well to treatment.

However, the inquest was told that the bleed would have increased her risk of an epileptic seizure. She was placed in a private single bed on the third floor of the maternity unit.

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 next day.

Joy turns to tragedy

Mr Downey wept today as he recalled how the joy and excitement of Darragh’s birth turned to tragedy. He said his sons, Sean and James, met their new brother in CUMH the day after he was born, and there was great excitement in the house about them coming home on the Monday - which was also his birthday.

He said he last spoke to Marie on Sunday evening, that she had had a sandwich and she was in good form. But he said he got a call from the hospital early on Monday asking him to get to CUMH quickly and to bring someone with him.

“I thought it was about registering Darragh’s name or something but then I got panicky,” he said.

“I tried Marie’s phone twice and got no answer and I thought Jesus Christ, what’s after happening.

“I called my father, I dropped the boys to creche, and my dad knew something had happened. I tried to convince myself it wasn’t serious.” He recalled how he was brought into a room and told that Marie was gone.

He told the coroner that when he asked medics to care for Darragh while the family tried to figure out what to do next, he said: “Then they said Darragh was part of the story as well. He was sent to hospital in Dublin and we didn’t know if we would be able to bury them together.” 

CUMH set up a review to examine the circumstances of the deaths. Its findings and recommendations have been ruled inadmissible by the coroner.

Lack of sleep

Mr Downey told the inquest that he was first told that Darragh was taken from Marie on the Sunday night before her death but when he questioned why he saw her signature on a medical chart at 3.30am and that she had written down, "breastfed left breast" the review committee said that they would examine the matter.

He was later told that Darragh would have been taken away from 3am to 7am to allow Marie sleep but when he asked for CCTV to be checked, it was established that Darragh was actually taken away at 3.59am and returned to Marie at 6.34am.

He said knowing that Marie got just two-and-a-half hours sleep shocked him because lack of sleep and exhaustion are reasons why Marie got seizures.

The inquest before a jury of four men and three women is set to continue over the next two days.

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