The tragic deaths of a mother and her baby boy could have been avoided if the concerns of medical staff about her mental health had been shared with her husband, an inquest has heard.
Darren Coleman told a sitting of Dublin District Coroner’s Court he had endured a three-year wait as “the only member of my family alive to speak” to voice his concerns about the care his wife had received for post-natal depression and the lack of information he was given by her doctors about her condition.
Mr Coleman’s wife, Nicola Keane – a 34-year-old paediatric nurse from Ballina, Co Mayo – jumped to her death off the M50 Westlink bridge in the early hours of October 22nd, 2020.
When Mr Coleman was woken a short time later by gardaí who called to the couple’s home at Shackleton Way, Lucan, Co Dublin, he discovered their seven-month-old son, Henry, in an unresponsive state in a spare bedroom.
The baby boy was pronounced dead shortly after being brought to Children’s Health Ireland at Crumlin.
Medical misadventure
A jury of six females and one male returned a majority 6-1 verdict of medical misadventure in relation to Ms Keane’s death.
The jury separately returned a unanimous narrative verdict in relation to baby Henry who they said had died from ingesting drugs which he had not been prescribed.
The jurors recommended that a post-natal depression programme should be built into ante-natal courses for both parents.
They also recommended the provision of mother and baby in-patient units in hospitals, if they were not already available.
Evidence was heard earlier that Ms Keane told doctors that she was concerned that she might “do something” because of her son’s irritability and her fears they were not bonding, although she repeatedly denied any intention of suicide or harming her son.
On the second day of the inquest on Tuesday, Mr Coleman told the coroner, Cróna Gallagher, that he had placed “complete and utter” trust in the professionals treating his wife.
He said it must have broken his wife’s heart when doctors told the couple that he should not leave her alone with their son.
“It completely hurt me to have to monitor the person I had been in a relationship with since I was 17 but I trusted the professionals,” he observed.
Medication
Mr Coleman believed he should have been informed that his wife’s medication had been increased twice around a month before her death as well as about any possible side-effects and that doctors had noted that she had “delusional beliefs and depressive episodes.”
“To read about this after their deaths has hurt me so much that I will never recover from it,” said Mr Coleman.
The inquest heard Ms Keane had also gone almost two months without a clinical assessment shortly before her death.
Mr Coleman told the inquest that there were 12 days when his wife received no communication from her care team.
He believed he should have been informed that she had not answered her phone on three occasions during this period.
“If I had been told even one piece of the information being withheld from me, I believe Henry and Nicola would not have died,” he added.
Mr Coleman said he would have immediately taken leave from his teaching job and “as hard as it would have been” would have taken any necessary steps to have his wife admitted to hospital.
“Henry was my focus and his safety was my priority. Nicola had a mental illness and should have been in a psychiatric hospital,” he remarked.
Mr Coleman also observed: “They allowed me to go to work every day knowing that she has been left alone with my child.”
Suicidal thoughts
He pointed out that his wife was never asked during six meetings with medical carers before he returned to work if she had any suicidal thoughts or intention of harming their son.
However, Mr Coleman said she was asked that question during seven out of eight contacts after he had gone back teaching and he questioned why there was such “an alarming shift.”
Mr Coleman said he discovered the meaning of his life on the day his son was born.
“It was just so special. I loved it and I loved him more than a person can describe,” he told the inquest.
Mr Coleman said he was “an extremely private person” who had waited for the inquest to have his opinion heard and listened to.
“Today is for me. Today is for Henry. Today is for Nicola,” said Mr Coleman.
He said he cried for the first time on July 7th 2020 when he feared his son might be taken from them after Ms Keane told a psychiatrist about a lack of a bond with her baby.
He recalled that she also stated that she would be happy if she didn’t wake up.
Post-natal depression
However, he said they were reassured by the psychiatrist, Elena Pérez, that 1 in 4 women suffered from post-natal depression.
Mr Coleman said he was really annoyed at the meeting when it was suggested to him that he “must start doing more.”
He described how he was told during a home visit by a mental health nurse three days later that he should not leave his wife alone with the baby.
As a result, Mr Coleman said he would stand outside the bathroom when she would be giving their son a bath.
He recalled stressing to doctors at another appointment in August 2020 that he was returning to his teaching job in two weeks but that they never mentioned any worries about this.
He also expressed surprise that his wife’s medication was being increased at a time when an improvement had been noticed in her condition.
Mr Coleman said the only time his wife was upset and annoyed was when she was given an information sheet on “helpful thinking styles” in September 2020 as she could not understand how that was the way of helping her.
He recalled how the weeks before the death of his wife and son were all about the future with plans for Henry’s christening and booking a short family holiday and looking forward to Christmas.
Psychiatric review
A paediatric psychologist at CHI Crumlin, Aoife Twohig, told the inquest that she had arranged an urgent psychiatric review of Ms Keane in July 2020 because of her concerns about Ms Keane’s mental health.
In other evidence, Dr Pérez said she assessed the risk with Ms Keane on the last occasion she saw her about a fortnight before her death as “extremely low” as she was improving.
Asked by counsel for Mr Coleman, Sara Antoniotti SC, why Ms Keane was not referred to perinatal mental health services, Dr Pérez said the deceased had been responding to treatment.
“We felt we were on the right pathway and doing what we needed to do,” she replied.
The psychiatrist, who broke down after leaving the witness box, confirmed that Ms Keane had never asked her not to pass information to her husband.
She could not recall if she had ever considered contacting Mr Coleman herself about him returning to work.
Asked by Dr Gallagher if it was possible that increasing Ms Keane’s dosage of an anti-depressant with serious side-effects had increased the risk of suicide or harming her son, Dr Perez replied: “I don’t think so.”
Assistant State Pathologist, Margot Bolster, said a postmortem showed that Ms Keane suffered multiple fractures which were injuries consistent with a fall from a height, while death would have been instantaneous.
Dr Bolster said alcohol and drugs had played no role in her death.
The pathologist said the lack of drugs in Ms Keane’s body meant she had not taken her prescribed medication for up to 20 hours before her death.
Dr Bolster said an autopsy on the baby revealed he had a lethal level for adults of an anti-psychotic drug (that had been prescribed for Ms Keane) which in combination with a sedative had caused his death.
She said it was impossible to say if the baby had been given an intentional overdose.
The inquest heard CCTV footage captured Ms Keane driving her Ford Fiesta across the M50 toll bridge as far as the Red Cow junction and returning back over the bridge and doubling back again.
Detective Inspector Brian Hanley said a text message was sent by Ms Keane to her husband around the first time she drove over the bridge at 3.12am.
The coroner said the message contained Ms Keane’s worry that she had harmed her son even before he was born and that he deserved a better life but it was too late as there was nothing to be done.
Dr Gallagher said it was clear that the deceased had “a very hopeless state of mind.”
Det Insp Hanley said most of the message had been composed over five weeks earlier.
He said gardaí believed there had been a deliberate act to give drugs to the baby, but he could not say what Ms Keane intended in doing so.
In a closing submission, Ms Antoniotti said Ms Keane’s son would not have died if she had received treatment in a hospital, while his death was also linked to the failure of doctors to discuss the risk to the baby with her husband.
Ms Antoniotti said Ms Keane was clearly mentally unwell with “fixed false beliefs.”
At the conclusion of the inquest solicitor for the HSE and CHI Crumlin, Simon Mills SC, said a number of verdicts were possible but not medical misadventure as suggested by Ms Antoniotti.
At the conclusion, solicitor for the HSE and CHI Crumlin, David Hickey, expressed sincere and heartfelt condolences to the Coleman and Keane families.
If you have been affected by any of the issues raised in this article, you can freephone the Samaritans 24 hours a day for confidential support at 116 123 or email jo@samaritans.org.
