The husband of a woman who died with their four-day-old baby boy at Cork University Maternity Hospital in March 2019 has told their inquest that their deaths could have been prevented.
Kieran Downey was giving evidence at the inquest into the deaths of his wife, Marie, and their son, Darragh, at the Coroner's Court in Cork.
Mr Downey listed better communications between doctors and hospital staff among a number of factors which, he said, could have prevented their deaths.
The inquest was told that Marie Downey had been diagnosed with epilepsy in 2010 and had had a number of seizures during two previous pregnancies.
Medical evidence on the cause of her death has not yet been given, but she was pronounced dead at Cork University Maternity Hospital on the morning of 25 March 2019, after being found in her single room with her baby critically injured underneath her.
Darragh was pronounced dead the following evening.
"The circumstances of their deaths, they could all have been prevented at many different points along the way," Mr Downey said.
"If there was communication between (obstetrician) Keelin O'Donoghue and (neurologist) Dr (Peter) Kinirons, and between both of them and the hospital and midwives, we wouldn't be here today," Mr Downey said.
"There were a whole list of things that should have been done that weren't and, if they were, we would be sitting at home without a care in the world."
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Mr Downey also said the failure to record the passing of his wife and son as two perinatal deaths at the hospital gave him no confidence in HSE systems designed to ensure that such deaths did not recur.
He claimed both were "completely forgotten" and implementation plans designed to prevent perinatal deaths at maternity hospitals "meant nothing".
Mr Downey and his legal team also criticised the decision not to admit as evidence a report by an external review panel into the deaths of his wife and son.
Mr Downey also said he was very disappointed that the clinical director of the hospital, Professor John Higgins, was not at the inquest to give evidence. He said he had written a personal letter to Professor Higgins asking him to attend.
Counsel for the Health Service Executive and CUMH, Conor Halpin, accepted that both deaths should have been published in a maternity patient safety statement for March 2019 - the month of their deaths - published online by the hospital.
He accepted that they were not.
However, he said that the deaths had been reported to the National Registry of Perinatal Deaths.
"If they can't do the basic recording of deaths, how can anyone trust the system," Mr Downey asked.
"It is not giving the correct facts that two people died and it doesn't show any transparency. I looked at it, because my wife and child should have been shown on it (maternity patient safety statement) six weeks after the event.
"It's a box-ticking exercise. These were people. They are our loved ones. They could be anyone's loved ones and they were not given the respect to record the factual information to be presented to the public."
Cork University Maternity Hospital apologised to Mr Downey and her family in August.
The hospital subsequently apologised at the inquest, through Mr Halpin, for the failure to publish the deaths of Marie and Darragh in the hospital's monthly maternity patient safety statement for March 2019.
Deaths due to missed opportunities - HSE
The National Clinical Lead for the HSE's epilepsy programme has said Marie and Darragh Downey's deaths were the result of missed opportunities to treat, monitor and prevent seizures occurring.
Neurologist Dr Ronan Kilbride told the inquest there was a lack of communication between Ms Downey's healthcare providers, and a lack of a formal care plan for women with epilepsy at Cork University Maternity Hospital.
Dr Kilbride was asked to review the case by Cork City Coroner Philip Comyn.
He said the recommendations of an expert external review panel were "the first steps" in the reduction of risk to ensure there was no recurrence.
"Marie and Darragh's passing undoubtedly represents inconsolable loss for their family," Dr Kilbride said.
"However, the lessons learned here and most particularly the actions taken as a result of this review and inquest can serve as an opportunity to improve the health and safety for women with epilepsy in Ireland."