Inquest Jury returns verdict of medical misadventure in relation to deaths of Kildorrery woman and her baby
A MAN whose wife and newborn son died within 33 hours of each other at Cork University Maternity Hospital (CUMH) has said he has no faith in the system and very little confidence that seismic changes will occur to prevent other families from experiencing such traumatic loss.
Mother-of-three Marie Downey from Kildorrery passed away on her husband Kieran’s birthday on March 25, 2019. Mr Downey had been due to collect his wife and their four-day-old son Darragh when he was called to attend at the hospital and informed Marie was dead. Darragh died the following day.
A three-day inquest at Cork Coroner’s Court determined that Mrs Downey had suffered an epileptic seizure in her private hospital room failing out of the bed and trapping her newborn son under her. Poignantly, the inquest heard from peri natal pathologist Dr Peter Kelehan who gave evidence that Darragh’s life could possibly have been saved if a member of staff had found mother and baby within four minutes or so of the tragedy occurring.
A jury recorded a verdict of medical misadventure in the case.
Reacting to the verdict Mr Downey said the HSE was “chaotic” and needed to make huge changes. Mr Downey stressed that his wife and son deserved more than the HSE getting involved in a ticking of the box exercise with no real concrete changes.
“There doesn’t even seem like there is a system. It is chaotic from the get go. Everything that was discussed during the last three-days proves the system (doesn’t work). There doesn’t even seem like there is a system,” he said.
Mr Downey said he couldn’t say with certainty that another women wouldn’t lose her life arising out of what Coroner Philip Comyn referred to as “certain systems failures.”
“Yes (it could happen again). It happened to Marie. I have no faith in the systems as they are and based on what we have heard it takes a long, long time for anything to be implemented. The HSE is a big organisation but there is people working there. The blame is often with the HSE — the letters. But people are responsible for making decisions and implementing them. And that is from the top all the way down. Unless these recommendations (from the jury and an independent review) 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,” said Mr Downey.
“Do I have faith (in the HSE) after the last three days? No. The recommendations from the jury are very good and should be implemented. But based on past history I have my doubts.”
He described the verdict and recommendations from the jury as being “good” but admitted the process was an ordeal .
Mr Downey stated that the set parameters of inquests restricted him in terms of what he was able to say to the jury.
“The process was very difficult. Made more difficult I suppose with being unable to voice my statements in the first place but also during the process in restricting what I could say. We have waited over two and a half years for this day to arrive. And while relieved this painful process is over our hearts remain broken,” said Mr Downey.
“We are grateful to the jury for their verdicts and recommendations which will we hope spare this kind of profound shock and tragedy from touching the lives of any other family ever again. Marie and I sought what we thought was the best possible care for her and paid to go private. We were let down and we feel failed by the system,” he added.
Mr Downey said that the day Darragh was born was the happiest time of his life.
The inquest had previously heard that Darragh’s older brothers Sean and James were “hyper’ with excitement about his arrival home to Knocknanevin, near Kildorrery.
They had met their brother in hospital and had one family photograph taken.
They couldn’t wait to have another sibling in the mix alongside their father Kieran and their beloved mother Marie who was a Novartis pharmaceutical employee who loved sport.
Mr Downey said that Marie and Darragh had a special place in the hearts of their loved ones.
“Marie and Darragh will never be forgotten. They will live in our hearts forever. They meant everything. I had never been so happy in my life on the day Darragh was born.
Marie was very loving and caring. An unbelievable mother to James, Sean and Darragh. Loved her parents Jim and Helen,” said Mr Downey.
Marie was the only child of Jim and Helen Cullinane and grew up in Ballyagran, Co Limerick. She was adored by her parents and in laws Tom and Elma and their extended family.
Mr Downey vowed to keep the pressure on the HSE to improve maternal care. However, he said he would like some private time following this very public and harrowing inquest.
“For my family and for Marie’s family we would like some privacy to be able to consume what we have heard and try to move on as best we can.”
He insisted his focus was on the well-being of his two boys James and Sean.
“Our two boys are great. The horrible tragic events of March 25 have left an impression on them even though they were very young. Something no child should ever go through. We speak about Mummy and Darragh every single day. They will never be forgotten. I wouldn’t wish (a tragedy like this) it on my worst enemy. It should never have happened. Hopefully it will never ever happen again, said Mr Downey.
The inquest heard that baby Darragh died of multi organ failure as a consequence of compression asphyxia whilst Marie sustained an upper cervical cord injury following a fall which occurred after she had an epileptic seizure.
Assistant State Pathologist Dr Margaret Bolster and Dr Kelehan reassured members of the Downey and Cullinane family that neither mother or baby would have suffered.
Dr Bolster said Mrs Downey “wouldn’t have known a thing — that is the only comfort I can give you.”
The HSE’s Senior Counsel Conor Halpin and SC Oonagh McCrann for consultant obstetrician Dr Keelin O’Donoghue told Coroner Philip Comyn that they wouldn’t be offering any submissions against a verdict by the jury of medical misadventure.
Doireann O’Mahony, Junior Counsel for the family, said it was inevitable and inescapable to do anything but conclude that he deaths were “foreseeable and preventable.”
Both she and Senior counsel Dr John O’Mahony were keen to emphasise that baby Darragh and Marie were so much more than numbers on a page and that changes ought to be made to prevent anyone from suffering such a heartbreaking loss again.
Ms O’Mahony said that the family often felt “adrift” during the inquest and were deeply troubled by a decision to exclude evidence from the report of an independent panel in to the deaths of mother and son.
The inquest heard that there was communication deficiencies and that Ms Downey’s obstetrician, Professor Keelin O’Donoghue, had failed to write to Ms Downey’s neurologist Dr Peter Kinirons about Marie’s third and last pregnancy.
Professor O’Donoghue said the failure to send a letter to Dr Kinirons was an oversight. Professor O’Donoghue told the inquest that she made an assumption that Mrs Downey’s neurologist, Dr Kinirons, knew his patient was pregnant.
“I regret that I didn’t write to him at that time. It is an oversight I regret.”
CUMH previously apologised to Kieran Downey for the deaths of Marie and Darragh while they were in their care.
At the opening of the inquest in August Mr Halpin read out an apology to the family whilst Ms McCann said her client Professor O’Donoghue wished to be associated with the HSE’s statement.
The apology was made on behalf of Professor John Higgins, Clinical Director of Ireland South Women and Infants Directorate at the South/Southwest Hospital Group.
Mr Downey said he had personally written to Professor Higgins imploring him to attend the inquest and was disappointed that he had failed to do so.
In the statement earlier this year the HSE said that they had carefully reviewed the management of Marie’s case along with a formal external review
“We have taken a number of steps with the ultimate aim of ensuring the safety of our patients at all times in CUMH,” read the statement.
The jury at the inquest last Thursday asked that the recommendations of an independent review of the case be implemented with a number of enhancements.
CUMH gave an update on progress to date . A number of improvements have been made but two key recommendations won’t be completed until next year.
These include the 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.
Marie Downey and baby Darragh were laid to rest in Castletown cemetery on March 30, 2019 following requiem mass at St Michael’s Church, Ballyagran.
At the funeral mass Kieran Downey recalled that the first dance played at his wedding to Marie was the Carpenters hit “We’ve only just begun,” He told mourners that they had “only just begun.”
“Marie was a beautiful person both inside and out. She had a heart of gold. She always put us first. We were her life and she was ours. Herself and Darragh are our special angels now,” said Mr Downey.
Marie had a passion for sport particularly Limerick GAA. She played camogie and hurling and camogie jerseys were placed by her coffin. Offertory gifts included one of her many handbags and a framed photograph of Darragh’s meeting with his big brothers James and Sean at CUMH.
Her sons also brought teddy bears to the altar.