A jury has returned verdicts of medical misadventure following an inquest into the tragic deaths of a mother and her newborn son at Cork University Maternity Hospital (CUMH) more than two years ago.
However, two of the key recommendations made following the deaths of Marie Downey, who had epilepsy, and her baby, Darragh, just 33 hours later, won’t be implemented at the hospital until next year.
The jury also issued amendments to recommendations that are contained in an independent report into the double tragedy in an effort to prevent future similar incidents.
They include changes to the electronic patient healthcare record system to flag comorbidities, improvements to ensure patient care plans can be put in place, and one-to-one supervision of vulnerable patients in single rooms to reduce the risk of adverse effects.
The verdict brought to an end a three-day joint inquest into the deaths of Ms Downey, 36, from Knockanevin near Kildorrery in north Cork, on March 25, 2019, and baby, Darragh, the following day, at CUMH, aged just four days old.
Ms Downey suffered an epileptic seizure, possibly while breastfeeding, and was found lifeless partially out of her bed in a contorted position, with Darragh in critical condition trapped underneath her.
The inquest was told that Ms Downey died from a broken neck from a fall following an epileptic seizure, and that Darragh died from acute respiratory failure due to compression asphyxia and multi-organ failure.
An independent review into the double tragedy, which was previously ruled by Cork City Coroner, Philip Comyn, as inadmissible at the inquest, made 11 recommendations in an effort to prevent future similar tragedies.
CUMH, through its legal representative, Conor Halpin SC, provided an update on the implementation of each of them.
It showed that while several improvements have been completed, two key recommendations, while in progress, won’t be completed until next year, including the “immediate appointment” of an epilepsy clinical nurse specialist or advanced nurse practitioner to the hub maternity hospital in each hospital group in the country, and the appointment of a consultant neurologist with an interest in maternity at Cork University Hospital.
In her submission to the jury, Mr Downey’s junior counsel, Doireann O’Mahony, said there had been a “catalogue of medical failures” and a “constellation of oversights” in these tragic cases.
“These deaths were foreseeable and preventable,” she said.
“No family should have to go through this. The hope is there will be learnings from it, which will lead to safer maternity services, not just in CUMH but across the country.”
She also said the bereaved family felt adrift at times during the coronial process and that Mr Downey was upset and distressed that the systems analysis report into the deaths had been omitted from the inquest.
That review has already found that the care delivered to Ms Downey during her pregnancy and in the postpartum period was not in line with HSE guidelines on the ‘management of women with epilepsy’.
CUMH has previously apologised to the Downey family for the deaths of Ms Downey and Darragh while in its care.