A man whose wife and newborn son died at Cork University Maternity Hospital (CUMH) says he has lost faith in the health system and has little confidence that changes will occur to prevent others experiencing similar trauma.
Kieran Downey was due to collect his wife Marie and baby Darragh from the hospital on March 25th, 2019, which was his birthday. However, he received a call asking him to come to the hospital and was informed there that Mrs Downey had died and Darragh was seriously injured. He died the following day.
A three-day inquest at Cork Coroner’s Court heard that Mrs Downey had an epileptic seizure in her private room which caused her to fall out of bed, trapping Darragh underneath her.
Perinatal pathologist Dr Peter Kelehan told the inquest that Darragh might have survived if a staff member had found them within about four minutes of the fall. A jury recorded a verdict of medical misadventure.
Reacting to the outcome, Mr Downey said the HSE was “chaotic” and needed to make huge changes. He said his wife and son deserved more than the HSE engaging in a box-ticking exercise with no 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 added that he could not say with certainty that another woman would not 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,” he said.
“The HSE is a big organisation...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.”
Mr Downey said that unless recommendations from the inquest jury and an independent review were implemented and disseminated in a very timely manner, they may prove to be “just ink on paper”.
He described the verdict and recommendations from the jury as “good” but said the inquest process was an ordeal.
“We have waited over 2½ years for this day to arrive. And while relieved this painful process is over, our hearts remain broken,” he said.
“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.”
Mr Downey said he and his wife had “sought what we thought was the best possible care” and paid for private healthcare during the pregnancy.
“We were let down and we feel failed by the system.”
‘Never forgotten’
He spoke of the family’s joy at Darragh birth, with the inquest hearing that Darragh’s older brothers, Seán and James, were “hyper” with excitement about mother and baby returning home to Knocknanevin near Kildorrery. They met their brother in hospital and had one family photograph taken.
“Marie and Darragh will never be forgotten. They will live in our hearts forever. They meant everything,” Mr Downey said. “I had never been so happy in my life as on the day Darragh was born. Marie was very loving and caring. An unbelievable mother to James, Seán and Darragh.”
Mrs Downey was the only child of Jim and Helen Cullinane and grew up in Ballyagran, Co Limerick. She worked for pharmaceutical firm Novartis and had a passion for sport, particularly Limerick GAA.
Mr Downey said he would keep the pressure on the HSE to improve maternal care but said appealed for privacy so the family could “consume what we have heard and try to move on as best we can”.
CUMH previously apologised to Mr Downey for the deaths of his wife and son while in the hospital’s care. The HSE said it had carefully reviewed the management of Mrs Downey’s case and that there had been 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.”
The jury at the inquest 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 had been made but it said two key recommendations would not be completed until next year.
These included hiring an epilepsy clinical nurse specialist or advanced nurse practitioner for the hub maternity hospital in each hospital group, and the appointment of a consultant neurologist with an interest in maternity at Cork University Hospital.