The man whose wife and newborn son died within 33 hours of each other following a cascade of errors at Cork University Maternity Hospital (CUMH) says he fears a similar tragedy could happen again unless systems change.
Kieran Downey, whose wife, Marie, and baby son, Darragh, died at CUMH in March 2019, called last night for the swift implementation of a series of enhanced recommendations made by a jury following a harrowing three-day joint inquest at Cork City Coroner's Court into their deaths.
The recommendations were based on 11 recommendations contained in a major report into the two deaths.
Mr Downey welcomed the verdicts of medical misadventure in relation to the deaths of both Marie and Darragh and the recommendations which he said were very good and should be implemented quickly.
“But, based on past history, I have my doubts,” he said.
In a statement, Mr Downey said he and his family waited two and a half years for the conclusion of the inquest.
“And while relieved this painful process is over, our hearts remain broken,” he said.
"We are grateful to the jury for their verdicts and recommendations which will, we hope, spare this kind of profound shocking tragedy from touching the lives of any other family ever again.
Speaking to reporters afterwards, he said he still has no faith in the system after hearing detailed and complex evidence over the last three days, which he said proves to him that the system is “chaotic from the very get-go”.
“Everything that was discussed for the last three days just, it doesn’t seem like there is even a system,” he said.
“The HSE is a big organisation but there are people working there. The blame is often with the HSE — the letters — but people are responsible for making decisions and implementing, and that’s from the top down, all the way down.
“And unless these great recommendations [from the jury] are going to be implemented and disseminated in a very timely manner, as has been proven down through the years, a lot of it is just ink on paper.”
He described the coronial process over the last three days as “very, very difficult” — made more difficult, he said, because he was not allowed to read certain statements into the record and was restricted from what he could say at certain times.
He said Marie and Darragh meant everything to him, and he described the day Darragh was born as one of the happiest days of his life.
However, he said the tragedy which befell them should never have happened and should hopefully never happen again.
The deaths of his wife and newborn son on the day they were due to be discharged home from CUMH has had a profound effect on his entire family, but especially his two older boys, James and Sean, he said.
“Our two boys are great — the horrible tragic events of March 25  have left an impression certainly on them, even though they were very young — it’s something no child should ever go through,” he said.
He described Marie as a very loving, caring, and unbelievable mother to James, Sean, and Darragh, and said she loved her parents, Jim and Helen. He described Darragh as “a beautiful baby”.
Kieran Downey has just one photograph of the family of five together. It was taken on the Saturday after Darragh was born when Kieran brought his two older boys to visit their mum and new baby brother in hospital. They all piled onto the hospital bed in Ms Downey’s room in the postnatal ward.
Mr Downey holds Sean in his arms while James pats his new brother’s head gently. Marie cradles baby Darragh in the centre.
Tragically, she suffered an epileptic seizure early on the Monday morning, March 25, 2019, most likely while breastfeeding Darragh, and fell partially out of the bed.
She was found dead on the floor at around 8am, with Darragh critically injured beneath her. He died the following day.
Mr Downey said: “There is no moving on. It’s just trying to care for my children and make sure that they have the best possible life as much as they can. We speak about mummy and Darragh every single day. They’ll never be forgotten.
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