Sunday, November 28

Judgment on medical mishaps in the death of mother and child – archyde

A medical mishap verdict has been reached for both Marie Downey and her newborn son Darragh Downey, who died more than two years ago after an investigation at Cork University Maternity Hospital (CUMH).

The jury spent over an hour reviewing their verdict and recommendations. They made a number of recommendations in the case and asked for the recommendations of the independent systems audit report to be implemented in the case.

They also called for enhancements to the recommendations, such as that drug administration should be recorded and tracked in health records, and stressed the importance of being physically present in a single hospital room when a person is at risk.

The four-day-old baby died after his mother had an epileptic seizure in her hospital bed and collapsed on him, with the weight of her lifeless body cutting off blood supply to his brain and other organs, the investigating committee heard.

The mother of three Marie Downey, 36, who lived in Knocknanevin, near Kildorrery, became Co Cork on 25 She. Despite major medical intervention, Darragh died 33 hours later. He was buried next to Marie on March 30, 2019 after their funeral mass in Mrs. Downey’s home town of Ballyagran.

autopsy

The expert Dr. Peter Kelehan, a retired pediatric pathologist at the National Maternity Hospital, said Baby Darragh died of compression asphyxia and multiple organ failure. Dr. Kelehan, who conducted the autopsy on Baby Darragh, said the child should have been found within a handful of minutes after his mother Marie fell on him for any chance of survival.

Dr. Kelehan said Darragh suffered from acute respiratory failure (compression asphyxia) and necrosis of multiple organs, particularly the heart and brain, in addition to a reperfusion injury. SC for the Downey family Dr. John O’Mahony said the family were upset about the decision to send baby Darragh’s body to St. Columcillle’s Hospital in Loughlinstown, County Dublin for an autopsy when Cork has a perinatal pathologist. Mrs. Downey’s autopsy was done in Cork.

Dr. Kelehan said he has performed autopsies “in the four provinces” since retiring. Due to the lack of replacements or appointments of pathologists, he has performed around 500 autopsies since stepping down from his post in 2009. He stated that he and another retired pathologist had been performing autopsies for several years.

He spoke of the importance of autopsies in infants by perinatal pathologists and emphasized that everyone involved in the process would be treated with great sensitivity.

Dr. Kelehan said the damage to baby Darragh’s brain was caused by prolonged compression on the baby’s chest after his mother suffered a medical episode and fell on him. He said the blood could not be pumped to baby Darragh’s brain and the degree of the brain’s abnormality was severe. The compression caused the blood supply to come to a complete standstill. Unfortunately, when Mrs. Downey’s body was removed from Baby Darragh, the damage was done, said Dr. Kelehan.

Dr. Kelehan said Baby Darragh was a well-fed, healthy baby. Dr. Kelehan added that, in his opinion, the mother fell on the baby, her weight “being distributed over the baby’s body.”

The deputy state pathologist Dr. Margaret Bolster conducted Ms. Downey’s autopsy at Cork University Hospital. She said Ms. Downey sustained an upper cervical vertebra injury that resulted in abnormal heart rhythms. She told the jury that the fall out of bed was due to an epileptic fit. She showed that the seizure increases the susceptibility to cardiac arrhythmias. She gave the neck injury as the immediate cause of death. No pathological examination of the brain can show a seizure, so she emphasized the importance of looking at the patient’s entire medical history.

“Enormous Tragedy”

Dr. John O’Mahony, SC of the Downey Family, said Dr. Bolster is a “beacon of independence” and the Downey family have full confidence in their abilities. He stated that the preponderance of evidence gave Marie’s position and demeanor when she was found on the ground, her collapse compatible with a fit such as a fall. Dr. Bolster agreed that it was. Dr. Bolster described the case as “an enormous tragedy”.

“You (Marie) would not have known anything. It would have been an immediate blackout. “

Doireann O’Mahony, Junior Counsel for the Family, asked if she could give the jury some lovely photos of Kieran Downey and his family. Coroner Philip Comyn agreed to her request. She emphasized that it had been “difficult days” for everyone involved in the case, but especially for the relatives of a loved one and mother.

She said that Marie Downey was under the care of Dr. Keelin O’Donoghue and that there was no plan for her pregnancy as an epileptic mother.

“The hospital made no attempt to monitor the levels of Lamictal (anticonvulsant) in her blood. Marie suffered severe postpartum bleeding and spent the night in an intensive care unit. Despite the clear risk factor for seizures and despite her known and explained pathological fear and paranoia that she might have a seizure while breastfeeding, she was taken from the intensive care unit to a single room. Your advisor was not on call over the weekend. Somebody else took care of Marie. It wasn’t her private obstetrician. “

She said excuses were “too little, too late” cases and that the family had waited a long 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 knowing this family and what they went through is one of the most terrible cases of fatal injuries that I have ever seen or dealt with. “

Ms. O’Mahony said the coroner’s system needs reform.

“The bereaved must be the focus of the investigation, and the family has sometimes felt helpless. It was a matter of great concern and concern to Kieran Downey that the Systems Analysis Review report was omitted from this investigation. He believed the review was done to prevent future deaths. It is very annoying for him that the report was not publicly available and could not be mentioned in this public forum. “

She added that there was a constellation of important clinical oversights.

“It is inevitable and inevitable to assume that the deaths were predictable and preventable.”

She said Ms. Downey was an only child and loved very much by her beloved family. She was a devoted wife, mother and daughter, heard the investigative committee.

Conor Halpin, SC for CUMH, said they would not offer filing for a medical mishap verdict in this case.

After the loss of Marie and Darragh, the Lord offered his condolences to the family. He was signed by Oonagh McCrann SC for Dr. Keelin O’Dononghue and Sgt Fergus Twomey on behalf of gardai, who also expressed their sincere condolences to the family.

Previously, Dr. Keelin O’Donoghue, obstetrician / gynecologist at CUMH, that her clinical impression when she found Mrs. Downey’s body in the hospital room had had a seizure and fell.

The investigation learned that Dr. Keelin O’Donoghue did not write to her patient’s neurologist about her treatment during Marie’s third pregnancy with Darragh. The doctor said it was an unfortunate oversight and apologized for it.

The commission of inquiry learned that two important recommendations of an independent systems review report on the case, which was closed in the summer, do not yet have to be implemented.

Maternity health

The review team strongly recommended the employment of a consulting neurologist interested in maternity health at Cork University Hospital. The investigation heard that this is “in progress”.

The report also recommended that all women with epilepsy attending a maternity ward in Ireland be offered and granted access to specialized care (epilepsy / neurology). To this end, the review team strongly recommended the immediate appointment of an Epilepsy Clinic Specialist or Advanced Nurse Practitioner at the Hub Maternity Hospital in each hospital group. According to the HSE, this is also “in the works”.

Since the tragedy struck, HSE guidelines for women with epilepsy have been distributed to all maternity units. Medicines for comorbidities if taken in hospital must be prescribed and the medication administered must be documented in the patient file.

Reference-www.nach-welt.com

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