Coroner Philip Comyn explained that such verdicts were indicative of a conclusion by the jury that the deaths were consistent with "certain systems failures".Earlier, a perinatal pathologist who conducted the post-mortem examination on Darragh Downey said he died as a result of multi-organ failure as a consequence of compression asphyxia.
Answering Senior Counsel Dr John O'Mahony for the Downey family, Dr Kelehan accepted that Darragh's life could have been saved if, for instance, a member of staff at the hospital had walked into the room and taken action within around four minutes of Ms Downey falling from the bed and trapping Darragh underneath her.
Senior counsel for the HSE Conor Halpin and senior counsel Oonagh McCrann, for consultant obstetrician Keelin O'Donoghue, told coroner Philip Comyn that "in ease of the family", they would not be offering any submissions against a verdict by the jury of medical misadventure.The jury then heard submissions from senior counsel Dr O'Mahony and barrister Doireann O'Mahony on behalf of the Downey family.
'Systems Failures' should not happen. Tragedies such as this should not happen. Seems that carelessness is not unknown in places where it a matter of life and death.