A man whose wife and newborn baby boy died in a Cork maternity hospital has called for the HSE to agree to admit in to evidence at their inquest a Systems Analysis Review report commissioned in the aftermath of the tragedy.
Mother of three Marie Downey, who lived in Knockanevin near Kildorrery, Co Cork, was found on the floor of her room at Cork University Maternity Hospital (CUMH) on the morning of March 25, 2019.
Mrs Downey, who was a native of Ballyagran in Co Limerick, was due to be discharged with her baby Darragh in a matter of days. She suffered an apparent epileptic fit while breastfeeding the infant and collapsed on Darragh who was found under her. Marie was pronounced dead at the scene whilst Darraigh passed away the following evening.
In August the inquest in to their deaths was opened by Cork city coroner, Philip Comyn. Legal representatives for CUMH expressed concern about the the admissibilty of an independent review carried out in to the care of Mary and Darragh Downey.
The review, which was subsequently ruled as inadmissible by the Coroner, was commissioned by Professor John Higgins, Clinical Director of CUMH. The inquest was opened on August 30th and adjourned for mention today.
Today at the Coroner's Court in Cork Mr Kieran Downey addressed Coroner Philip Comyn. He asked the HSE to agree to admit the review in to evidence. He said there was a "cascade of events" prior to death of his wife and child.
Junior Counsel for the family, Doireann O'Mahony, said that Mr Downey's "only remaining hope" is that no other family will have to endure a similar tragedy.
"But this will only be possible with a full and thorough investigation which leaves no stone unturned.
"We are now formally calling on the HSE to agree to the admission into evidence of the Systems Analysis Review report commissioned by Professor John Higgins, Clinical Director of CUMH.
"We are told that the report has been accepted in full, and that all eleven of its recommendations are to be implemented.
"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. "
Ms O'Mahony said that for a hospital that says that it “strives for clinical excellence”, CUMH would seem startlingly averse to public scrutiny, and learning from its mistakes.
"This is a matter of significant public importance. It is Mr Downey’s express request that the HSE do the right thing now, and agree to the admission of the report."
Solicitor for the HSE, Eamonn Harrington, refuted any suggestion that there was anything but full disclosure in relation to the "tragic incident."
Mr Harrington said that HSE was committed to open disclosure and that immediate action was taken following the deaths of mother and son. The court heard that a full external review was carried out in relation to the deaths which was shared with the family of the deceased.
He said a ruling on the admissibilty or not of the report had already been made by Mr Comyn whilst rejecting any allegations of secrecy by the HSE. Mr Harrington also extended his sympathy to Mr Downey following his loss.
Mr Comyn said that he had given a written judgement which explained his reasons for not allowing the review to be admitted in to evidence. He said he fully understood Mr Downey's position of not wanting to see other families suffer losses such as his own.
A full inquest in to the deaths is expected to be heard on the week of November 16th subject to final confirmations on venues. A jury will be present at the inquest.
At the opening of the inquest in August Conor Halpin SC for the HSE read out an apology to the family.
The apology was made on behalf of Professor John Higgins, Professor of Obstetrics and Gynaecology and Clinical director of Ireland South Women and Infants Directorate at the South/Southwest Hospital Group.
He said that CUMH would like to sincerely apologise to Ms Downey's husband, Kieran, their sons, James and Sean, and to Marie‘s parents and family for the events that occurred while Marie and Darragh were under the care of CUMH "which resulted in the tragic loss of their lives."
"We cannot possibly comprehend the devastating impact these losses have had on you and your family," he said.
"We have carefully reviewed the management of Marie‘s case along with a formal external review of which you were part.
"We have taken a number of steps with the ultimate aim of ensuring the safety of our patients at all times in CUMH.
Oonagh McCrann SC, representing Obstetrician, Professor Keelin O’Donoghue, said her client wished to be associated with the HSE’s apology.
“She would like to express her deepest regret and sadness at the death of the late Mrs Downey and baby Darragh and indeed I would also like on my own behalf, and on behalf of my solicitor Justine Sayers to express our deepest sympathy for the terrible tragedy.”