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The Downey family. Kieran Downey
marie downey

Jury in mother and baby inquest returns verdict of medical misadventure

The jury made a series of recommendations in the case.

THE JURY AT the inquest into the deaths of Marie Downey and her four-day-old son Darragh have returned verdicts of medical misadventure in both cases.

The jury spent over an hour considering their verdict and recommendations.

Earlier, the inquest heard that Darragh 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.

Mother of three Marie Downey, 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 25 March, 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 Marie following their joint funeral mass in Marie Downey’s native Ballyagran.

Expert witness Dr Peter Kelehan, who is a retired Paediatric Pathologist National Maternity Hospital, said that baby Darragh died of compression asphyxia and multi organ failure.  

Dr Kelehan, who carried out the postmortem on baby Darragh, said that the infant  would have needed to have been found within a handful of minutes of his mother Marie falling on top of him to stand any chance of survival.

Assistant State Pathologist Dr Margaret Bolster carried out the postmortem on Marie Downey at Cork University Hospital.

She said Marie 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 stated 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.

Dr John O’Mahony, SC for the Downey family, said that Dr Bolster was a “beacon of independence” and that the Downey family had every confidence in her ability.

He stated the preponderance of the evidence was given the position and posture of Marie when she was found on the floor her collapse was consistent with a seizure like fall. Dr Bolster agreed this was the case. Dr Bolster described the case as “an enormous tragedy.”

“She (Marie) wouldn’t have known a thing. 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 that 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 that Marie 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 Lamictal (anticonvulsant medication) in her blood. Marie suffered a major post parted 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 stated that apologies were cases of “too little, too late” and that the family had waited for a considerable amount of 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.”

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

Conor Halpin, SC 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 Marie Downey in the hospital room her clinical impression was that she had suffered a seizure and had a fall. 

The inquest heard that during Marie’s third pregnancy with Darragh Dr Keelin O’Donoghue didn’t write to her patient’s neurologist about her care. The doctor said that this was a regrettable oversight and apologised for same.

Conor Halpin, SC, for the HSE offered his heartfelt condolences to the family following the loss of Marie and Darragh.

He was joined by Oonagh McCrann SC for Dr Keelin O’Donoghue and Sgt Fergus Twomey on behalf of gardaí who also offered their sincere sympathy to the family.

Dr John O’Mahony, SC, on behalf of the family said the inquest would stand out in the “annals of history” in relation to the care of pregnant women.

The jury made a series of recommendations in the case.

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 Cork University Hospital. The inquest heard that this is ‘in progress”.

The report also recommended that access to specialist nurse services 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 comorbidities when taken by inpatients must be prescribed and the administration of medication must be documented in the patient’s healthcare record.

Olivia Kelleher
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