A MAN WHOSE wife and newborn son died within 33 hours of each other at Cork University Maternity Hospital (CUMH) has claimed that 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 passed away on her husband Kieran’s birthday on 25 March, 2019. He had been due to collect her 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 Marie 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 perinatal 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 widower Kieran 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.”

Kieran Downey said he couldn’t say with certainty that another woman 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.

“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.

“We are grateful to the jury for their verdicts and recommendations which we hope will 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.” 

HSE chief executive Paul Reid apologised to the Downey family and described the case as “extremely tragic”.

“My heart and everybody’s heart can only go out to the family. [I'm] extremely sorry for what happened. This is an extremely traumatic event for everybody,” Reid said.

“When something like this goes wrong and indeed tragically wrong, we have to learn from it. We have to implement learnings that come from this and other tragic cases.”