CUMH deaths 'result of missed opportunities to treat, monitor, and prevent seizures'

Mother with epilepsy and four-day-old baby boy died in hospital
CUMH deaths 'result of missed opportunities to treat, monitor, and prevent seizures'

Kieran Downey, husband of the late Marie Downey at Cork city Coroner’s Court for the inquest into the deaths of his 36-year-old wife, Marie, and their four-day-old baby boy Darragh, at Cork University Maternity Hospital more than two years ago. Picture: Cork Courts Limited

An expert in epilepsy said the deaths of a mother with epilepsy and her newborn son in Cork University Maternity Hospital (CUMH) were as a result of missed opportunities to treat, monitor, and prevent seizures.

Neurologist, Dr Ronan Kilbride, the national clinical lead of the HSE’s epilepsy programme, made his comments as he gave evidence yesterday at the joint inquest into the death of Marie Downey, and the death of her infant son, Darragh, in CUMH in March 2019.

Ms Downey’s husband, Kieran, wept as he recalled how his wife died just hours before he was due to bring her and Darragh home.

He told Cork City Coroner Philip Comyn of the sheer joy as his sons, Seán and James, visited their mother and met Darragh in CUMH the day after his birth on Friday, March 22, 2019, and how they were all very excited about welcoming him home on the Monday.

But he said that joy and excitement turned to tragedy when he got a phone 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 said he was brought into a room and was told that Marie was gone and when he asked medics to care for Darragh while the family tried to figure out what to do next, he was told “Darragh is part of the story as well”.

The inquest heard that Ms Downey was attending neurologist Dr Peter Kinirons for the management of her epilepsy and was very good at taking her anticonvulsant medication, lamotrigine, sold as lamictal.

Marie Downey and her son Darragh who both died in tragic circumstances at CUMH.
Marie Downey and her son Darragh who both died in tragic circumstances at CUMH.

When she was pregnant with Darragh, Ms Downey was under the care, as a private patient, of consultant obstetrician, Dr Keelin O’Donoghue, who had also overseen her previous pregnancies.

But in a letter read into the record, Dr Kinirons said he wasn’t aware of her third pregnancy, and wasn’t consulted by CUMH at any stage during it.

During the course of her first pregnancy in late 2013, Ms Downey stopped taking her epilepsy medication and suffered a seizure at about 30 weeks, before giving birth to her first child in February 2014.

The medication was then reintroduced at a slightly higher dose and she took it throughout the next two pregnancies.

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. 

Mr Downey also said his wife knew that tiredness may cause seizures.

Shortly after she gave birth to Darragh, she experienced a significant postpartum haemorrhage, losing up to a fifth of her blood. 

She was treated, and recovered and was placed in a private single bed room and on the Sunday night, she asked for help breastfeeding Darragh.

But at around 8am the following morning, she was found unresponsive and lying partly out of her hospital bed with Darragh trapped under her in critical condition.

Despite immediate medical attention, she was pronounced dead. Darragh died the next day.

Dr Kilbride, who reviewed her case for the coroner, said Ms Downey had sought and found successful treatment for her generalised epilepsy in her 20s, and self-administered lamotrigine but stopped taking it in the early stages of her first pregnancy.

He told the coroner that the risk of seizure increases in the later stages of pregnancy when the kidneys’ ability to clear medication from the blood increases by between 40% and 50%.

He said a post mortem found just 1.2mg/l of lamotrigine in her system when the regular concentration should be between 3.5 to 12mg.

He said the increased risk of seizure continues for up to 72-hours post-delivery because of falling hormonal levels, which is why the blood levels of pregnant women with epilepsy should be monitored.

He said Ms Downey had suffered a “sudden and without warning” full convulsive seizure shortly or immediately before death, which would have reduced her drive to breathe.

He said the deaths of Ms Downey and Darragh were as a result of “missed opportunities to treat, monitor and prevent seizures” occurring most notably as a result of a lack of communication between her health care providers and the lack of a formal care plan for women with epilepsy at CUMH.

He said their deaths are an incalculable loss for their families, but lessons can be learned to improve the safety of women with epilepsy in Ireland, with lessons for all medical professionals who interacted with Ms Downey on the need for communication and a structured approach to seizure reduction.

He said access to specialist epilepsy or neurology nurse services must be offered and provided to all women with epilepsy attending maternity services in Ireland, and that the administration of their anticonvulsant medication should be supervised while they are in a maternity hospital.

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

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