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'Special angels' Care of mum who died with baby at Cork hospital ‘not in line with HSE recommendations’

It is feared Mrs Downey - who had a history of epilepsy - suffered a seizure and was then fatally injured as she apparently fell out of bed in her single room.

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Mother-of-three Marie Downey

Mother-of-three Marie Downey

Mother-of-three Marie Downey

An external review into the death of a mother of three and her newborn baby at a Cork maternity hospital made 11 key recommendations - and found that her care was not in line with Health Service Executive (HSE) recommendations.

It was ordered after the death of Mrs Marie Downey (36) at Cork University Maternity Hospital (CUMH) on March 25 2019.

It is feared Mrs Downey - who had a history of epilepsy - suffered a seizure and was then fatally injured as she apparently fell out of bed in her single room.

Tragically, she partially fell on her newborn son, Darragh, who she was nursing.

He died the following day despite desperate efforts to try to stabilise the infant's condition.

Mrs Downey was pronounced dead shortly after she was discovered.

Two reviews were launched into the circumstances of the double tragedy - one external review was ordered by then Health Minister Simon Harris and the second by the hospital group itself.

The external review was chaired by Prof Norman Delanty, consultant neurologist at Beaumont Hospital in Dublin.

It began in May 2019 and was completed last April.

A Cork coroner's inquest into the deaths of Mrs Downey and her son opened before Coroner Philip Comyn this morning.

The opening session of the inquest was dominated by legal argument.

Submissions were made to Mr Comyn by the legal team for the Downey family, Dr John O'Mahony SC and Doireann O'Mahony BL and by the legal team for the HSE, CUMH and medical team, Conor Halpin SC and Oonah McCrann SC.

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A number of members of Mrs Downey's family are attending the inquest led by her husband, Kieran.

The inquest hearing is expected to be at held for two days.

Medical evidence on the cause of death for Mrs Downey and her newborn son is expected to be delivered by Assistant State Pathologist Dr Margaret Bolster to the inquest on Monday afternoon.

The external review found that: "the care delivered...during her pregnancy and in the postpartum period was not in line with the recommendations of HSE 2018 Practice Guide for Women With Epilepsy (WWE)."

It noted an absence of communication between the consultant obstetrician and consultant neurologist and no evidence of clinical nurse specialists in neurology being involved in Mrs Downey's care.

It is understood CUMH has accepted all 11 of the review findings.

The recommendations include:

1 - In terms of patients with epilepsy, the HSE guidance should be widely circulated to all maternity units. All relevant clinical staff must be educated and caring for women with epilepsy in pregnancy and childbirth.

2 - When a pregnant woman has an underlying health issue information related to the impact of the pregnancy on the particular condition must be sourced such that appropriate care plans can be developed and documented.

3 - Access to specialist nurse services (epilepsy, neurology) must be offered and provided to all women with epilepsy attending maternity services in Ireland. To this aim, the review team strongly recommends immediate appointment of an epilepsy clinical nurse specialist or advanced nurse practitioner to the hub maternity hospital in each hospital group.

4 - Medications for co-morbidities when taken by inpatients must be prescribed and the administration of the medication must be documented in the patient’s health record.

5 - Improved use of electronic prescribing, if available, is recommended in order that inappropriate medication is avoided.

6 - Pre-order medication should be prescribed when indicated.

7 - There is an urgent requirement for a level of standardisation in some of the functions of the electronic patient record. It must be made possible to flag-risk and co-morbidity on the banner bar in a consistent fashion and that critical information is displayed immediately under the banner bar for all users.

8 - Single room accommodation for postnatal women is considered optimal for privacy and dignity and is the model for all future hospital infrastructure development. For women with epilepsy, new and evolving seizure warning devices should be considered in individual circumstances.

9 - Access to a patient’s information must be restricted only to key staff members immediately after a serious event to maintain and protect patient confidentiality. This followed concerns expressed by the (Downey) family about the inappropriate release of certain information to the media in the immediate aftermath of Mrs Downey’s death.

10 - HSE recommendations on infant sleeping guidelines should continue to be promoted ensuring that the baby is placed in the cot is beside the mother when not being fed or comforted.

11 - The review team strongly recommend that a consultant neurologist with an interest in Maternity health be appointed at Cork University Hospital.

Two years ago, Mrs Downey was buried with her infant son, Darragh, cradled in her arms.

Her husband, Kieran, hailed them at the Requiem Mass as their family's new "special angels."

Mrs Downey nee Cullinane was brought up in a GAA-obsessed Limerick parish of Ballyagran - and lived with her husband, Kieran, and two older sons, James and Sean, in nearby Knockanevin outside Kildorrery.

Mourners were told two years ago that Mrs Downey was "a beautiful person inside and out."

"She had a heart of gold. She always put us first. Herself and Darragh are our special angels now," Mr Downey said.

The Offertory Gifts reflected the deep passions of Mrs Downey's life.

The mother of three adored sports - and four GAA jerseys from Ballyagran, Kildorrery, Douglas and Limerick were brought to the altar.

Also offered was a photo taken in Cork University Maternity Hospital (CUMH) when little Darragh met his two big brothers for the first time.

Mourners were told that tears of joy at the birth of little Darragh on Friday evening had turned to tears of anguish, pain and despair by Monday morning when Mrs Downey was found unconscious on the floor of her room in CUMH.

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