Verdict of medical misadventure recorded at inquest into deaths of mother and baby at Cork University Maternity Hospital

A VERDICT of medical misadventure was recorded for both Marie Downey and her baby son Darragh after a jury spent over an hour considering their verdict and recommendations at the inquest.

The four-day-old baby died after his mother had an epileptic seizure in her hospital bed, collapsing on top of him with the weight of her lifeless body stopping blood supply to his brain and other organs, the inquest heard.

Mother of three, Marie Downey, aged 36, who lived in Knocknanevin, near Kildorrery, Co Cork, was found dead on the floor of her private room at Cork University Maternity Hospital (CUMH) shortly after 8am on March 25, 2019, with her baby son Darragh critically injured under her.

In spite of major medical intervention, Darragh died 33 hours later. He was laid to rest alongside his mother following their joint funeral Mass in Ms Downey’s native Ballyagran on March 30, 2019.

Expert witness Dr Peter Kelehan, a retired pediatric pathologist at the National Maternity Hospital, said baby Darragh died of compression asphyxia and multi-organ failure.

Dr Kelehan, who carried out the autopsy on baby Darragh, said that the infant would have needed to have been found within a handful of minutes of his mother falling on top of him to stand any chance of survival. He said Darragh suffered acute respiratory failure (compression asphyxia) and necrosis of multiple organs, particularly the heart and brain, in addition to a reperfusion injury.

Senior counsel for the Downey family, Dr John O’Mahony, said that the family had been upset at the decision to send the body of baby Darragh to St Columcille’s Hospital, in Loughlinstown, Co Dublin, for an autopsy when Cork has a perinatal pathologist. The autopsy of Ms Downey was carried out in Cork.

Dr Kelehan said the damage to the brain of baby Darragh was caused by sustained compression on the baby’s chest after his mother suffered a medical episode and fell on top of him. He stated blood could not pump to the brain of baby Darragh, and the level of abnormality to the brain was severe. The compression caused the blood supply to totally stop. Unfortunately, when the body of Ms Downey was taken off baby Darragh, “the damage was done”, Dr Kelehan stated.

Dr Kelehan said baby Darragh was a well-nourished, healthy baby. Dr Kelehan added that it was his opinion that the mother fell on top of the baby with her weight being “distributed across the baby’s body”.

Assistant state pathologist Dr Margaret Bolster carried out the autopsy on Ms Downey at Cork University Hospital (CUH). She said Ms Downey suffered an upper cervical spinal cord injury, which caused cardiac arrhythmia. She told the jury that the fall out of the bed occurred because of an epileptic seizure. She gave evidence that the seizure increased vulnerability to cardiac arrhythmia. She also stated that the immediate cause of death was the neck injury. No pathological examination of the brain can show seizure, so she stressed it was important to look at the whole history of the patient.

'BEACON OF INDEPENDENCE'

Dr O’Mahony, for the Downey family, said Dr Bolster was a “beacon of independence”, and that the family had every confidence in her ability. He stated the preponderance of the evidence was, given the position and posture of Ms Downey when she was found on the floor, her collapse was consistent with a seizure-like fall.

Dr Bolster agreed, describing the case as “an enormous tragedy”. 

“She [Ms Downey] wouldn’t have known a thing,” she said. “It would have been an instant blackout.”

Doireann O’Mahony, junior counsel for the family, asked if she could distribute some beautiful photographs of Kieran Downey and his family to the jury. Coroner Philip Comyn agreed to her request. She stressed it had been a “difficult few days” for all involved in the case, but most importantly for the loved ones of a beloved wife and mother.

She said Ms Downey was under the care of Dr Keelin O’Donoghue, and that there was no plan of care in place for her pregnancy as an epileptic mother.

“No attempt was made by the hospital to monitor the levels of [anti-convulsant medication] Lamictal in her blood,” she said.

“Marie suffered a major postpartum haemorrhage and spent the night in a high-dependency unit. In spite of the clear risk factor for seizures, and in spite of her known and stated morbid fear and paranoia that she would have a seizure while breastfeeding, she was taken from the high-dependency unit and placed in a single room. Her consultant was not on call over the course of the weekend. Somebody else was looking after Marie. It wasn’t her privately contracted obstetrician.”

She said that apologies were “too little, too late”, and that the family had waited for a considerable time for the case to be heard.

“Every death is a tragedy, and there is no hierarchy of tragedies when it comes to grief. But having known this family and what they have been through, it ranks as the most horrific of fatal injury cases I have seen or inquests I have ever dealt with.”

Ms O’Mahony also said that the coroner’s system is in need of some reform.

“Bereaved families must be at the centre of inquest, and the family have felt adrift at times. It was of great upset and distress to Kieran Downey that the systems analysis review report was omitted from this inquiry. His belief was the review was undertaken to prevent future fatalities. It is most upsetting for him that the report was not allowed into the public domain and was not allowed to be referenced in this public forum.”

She added that there was a constellation of major clinical oversights in the case.

“It is inevitable and inescapable to assume that the deaths were foreseeable and preventable,” she said.

She said Ms Downey was an only child and much loved by her family. She was a dedicated wife, mother, and daughter, the inquest heard.

Conor Halpin, for CUMH, said that they would not be offering any submission against a verdict of medical misadventure in the case.

Earlier, Dr Keelin O’Donoghue, obstetrician/gynaecologist at CUMH, said that when she found the body of Ms Downey in the hospital room, her clinical impression was that she had suffered a seizure and had a fall.

The inquest heard that during Ms Downey’s third pregnancy with Darragh, Dr O’Donoghue did not write to her patient’s neurologist about her care, for which she expressed regret.

Mr Halpin, for the HSE offered his heartfelt condolences to the family. He was joined by Oonagh McCrann for Dr O’Dononghue and Sgt Fergus Twomey on behalf of gardaí who also offered their sincere sympathy.

Mr O’Mahony, on behalf of the family said the inquest would stand out in the “annals of history” in relation to the care of pregnant women. He also thanked coroner Philip Comyn and the jury for all of their assistance since the tragedy occurred. Mr Comyn applauded the jury for their “attention to detail” and their willingness to sit late to ensure the inquest was completed.

He added it was the first double tragedy that he had had to deal with in his career and he hoped it was the last, “There is very little I could possibly say to Mr Downey and the family about these deaths. They are extremely tragic for you Mr Downey and for [your sons] James and Seán. It is also very difficult for James and Helen [Ms Downey’s parents). For Marie death would have been instantaneous she would not have suffered. For baby Darragh he lapsed into a coma immediately and would not have suffered.”

VERDICT

A verdict of medical misadventure was recorded for both Marie and Darragh Downey. The jury spent over an hour considering their verdict. They asked that the recommendations of the independent systems review report into the case be implemented. They also asked for enhancements to the recommendations such as that the administration of medicines be recorded and traceable in health records. They also emphasised the importance of a physical presence in a single hospital room when a person is vulnerable.

The inquest heard that two key recommendations of an independent systems review report into the case concluded this summer have as yet to be implemented. The review team strongly recommended that a consultant neurologist with an interest in maternity health be appointed at CUH. The inquest heard that this is “in progress”.

The report also recommended that access to specialist nurse services (epilepsy/neurology) must be offered and provided to all women with epilepsy attending maternity services in Ireland. To this aim, the review team strongly recommended the immediate appointment of an epilepsy clinical nurse specialist or advanced nurse practitioner to the hub maternity hospital in each hospital group. This is also “in progress” according to the HSE.

Since the tragedy occurred, HSE guidance on women with epilepsy has been widely circulated to all maternity units. Medications for co morbidities when taken by inpatients must be prescribed and the administration of medication must be documented in the patient’s healthcare record.