Husband tells inquest he believes deaths of wife and son at CUMH could have been prevented

A man whose wife and four day old son died at Cork University Maternity Hospital (CUMH) has told their inquest that he believes that they would still be alive if medics and staff followed guidelines for the care of pregnant women with epilepsy.

Mother of three Marie Downey (36) who lived in Knockanevin near Kildorrery, Co Cork was found on the floor of her private room at CUMH on the morning of March 25, 2019. She was expected to be discharged from hospital that day with her newborn baby Daragh.

However, she was found dead on the floor of her room with her baby Darragh critically injured under her. Darragh passed away the following evening.

Her husband Kieran told an inquest in to their deaths that the day his wife died was his birthday and that his plan had been to collect her after she was discharged from hospital. He had dropped their “excited” sons to crèche that morning.

Marie Downey had been diagnosed with epilepsy in 2010 but Mr Downey stated that her health was good and her seizures were rare.

Mr Downey said that he received a phonecall from the hospital on the morning of March 25, 2019 to come and to bring somebody with him. Initially he thought that the call involved him registering the name of the baby but alarm bells went off when he was informed that he needed a person with him. The call made him "panicky."

He said he tried to call his wife's phone but it went unanswered. He went to CUMH where he was taken in to a room and informed that his wife Marie was dead. He was also told that his son Daragh "was part of the story." 

Darragh also passed away with Mr Downey stressing that his grief was exacerbated by the fact that, whilst Marie's postmortem was carried out in Cork, baby Darragh was sent to Dublin to be examined.

"Darragh was sent to Dublin which was horrific. We didn't know if we would be able to have a funeral with Darragh and Marie together."

Medical evidence yet to be heard 

Medical evidence as to the cause of death has yet to be given. However, Mr Downey told Coroner Philip Comyn that he believed the deaths of mother and baby could have been prevented if there had been better communication between medics about her epilepsy.

"There is a whole list of things that should have been done that weren't and if they were we would be sitting at home without a care in the world. The circumstances of their deaths could have been prevented at many different points along the way. "

Mr Downey expressed his belief that there was a lack of communication between the obstetrician and the neurologist treating his wife in relation to her care and the dangers posed by her epilepsy. He said he was "drip fed" information after the death of mother and son and that the versions of the story "kept changing."

He said that his wife rang the bell for help from her private room nine times between midnight and 3.30am on the night before she died but she 'didn't seem to be a priority'.  

He stated that his wife's private room was the second last room away from the nursing station.

Mr Downey said he was stunned to find out after his wife's death that she had experienced epileptic seizures three days after she had their son Sean in 2016. Mr Downey felt "hit by a tonne of bricks" when he came across this information.

“From reading the draft HSE report there was a note which turned my stomach completely. This was a line where it was stated that on the 3rd day postpartum after Sean that Marie may have had an epileptic event and that was news to me as it was never communicated to me.“

He stated that this was “soul destroying” news as it would have had a bearing on how she was treated in her next pregnancy.

"It seemed to have been known (in the hospital) and yet two and a half years later we were in the same position.” 

Mr Downey said that there was a distinct lack of communication amongst medics about his wife’s condition of epilepsy.

“If there was communication between Dr Keelin O'Donoghue (obstetrician) and Dr Peter Kinirons (neurologist) and between both of them and midwives we wouldn't be here today."

Mr Downey said his wife and son were "completed forgotten" by the hospital. 

Six weeks after their deaths he looked up the Maternity Patient Safety Statement for March of 2019 and found that the deaths of his loved ones hadn't been recorded. He stressed that he was shocked by what he perceived as a "lack of transparency" by the hospital.

“If you can't even do basic recording how can anyone trust the system? It is not giving the correct facts that two people died and it doesn't show any transparency. I looked at it, because my wife and child should have been shown on it (maternity patient safety statement) six weeks after the event.

"It's a box-ticking exercise. These were people. They are our loved ones. They could be anyone's loved ones and they were not given the respect to record the factual information to be presented to the public."

Apology for the failure to record the deaths

Conor Halpin, SC for CUMH, apologised to Mr Downey for the failure to record the deaths in the hospital’s monthly patient statement statement for March 2019. However, he said the deaths were reported to the National Register of Perinatal deaths.

Mr Downey said there was a lot changes in regard to the story of what occurred in the hours before the tragedy unfolded.

“I questioned the fact that I saw Marie's signature on the chart at 3.30am and that she had written down, "breastfed left breast.” 

"The Review committee said that they would look into it and then they came back and they said that Darragh would have been taken away from 3.00am to 7.00am, so she (Marie) would have got ample sleep.

"I would of thought that four hours was reasonably good sleep to get. But I asked to check the CCTV and again after another review meeting they told me that Darragh was actually taken away at 3.59am, almost four o'clock in the morning, and had been returned to Marie at 6.34am - so two and a half hours sleep which shocked me.

"I suppose because lack of sleep and exhaustion are reason why Marie certainly got seizures. So I wouldn't have thought she would ring the bell after such little sleep to feed Darragh when it was not required.” 

Mr Downey said that he had no faith in the HSE and that implementation plans to prevent peri natal deaths “meant nothing.” 

He added that Marie had expressed apprehension about breast feeding in relation to having epileptic seizures but that she was “left to breastfeed alone” after a traumatic birth where she experienced significant blood loss.