A jury has returned verdicts of medical misadventure following an inquest into the tragic deaths of a mother and her newborn son at Cork University Maternity Hospital (CUMH) more than two years ago.
However, two of the key recommendations made following the deaths of Marie Downey, who had epilepsy, and her baby, Darragh, just 33 hours later, won’t be implemented at the hospital until next year.
The jury also issued amendments to recommendations that are contained in an independent report into the double tragedy in an effort to prevent future similar incidents.
They include changes to the electronic patient healthcare record system to flag comorbidities, improvements to ensure patient care plans can be put in place, and one-to-one supervision of vulnerable patients in single rooms to reduce the risk of adverse effects.
The verdict brought to an end a three-day joint inquest into the deaths of Ms Downey, 36, from Knockanevin near Kildorrery in north Cork, on March 25, 2019, and baby, Darragh, the following day, at CUMH, aged just four days old.
Ms Downey suffered an epileptic seizure, possibly while breastfeeding, and was found lifeless partially out of her bed in a contorted position, with Darragh in critical condition trapped underneath her.
The inquest was told that Ms Downey died from a broken neck from a fall following an epileptic seizure, and that Darragh died from acute respiratory failure due to compression asphyxia and multi-organ failure.
An independent review into the double tragedy, which was previously ruled by Cork City Coroner, Philip Comyn, as inadmissible at the inquest, made 11 recommendations in an effort to prevent future similar tragedies.
CUMH, through its legal representative, Conor Halpin SC, provided an update on the implementation of each of them.
It showed that while several improvements have been completed, two key recommendations, while in progress, won’t be completed until next year, including the “immediate appointment” of an epilepsy clinical nurse specialist or advanced nurse practitioner to the hub maternity hospital