Narrative verdict follows inquest into Leona Cusack’s death
A narrative verdict has been recorded at the inquest into the death of Leona Cusack, a 33-year-old woman from Ballycasey, Shannon, Co Clare. Leona died at University Hospital Limerick (UHL) on 18 February 2024 from cardiorespiratory failure, a day after suffering a miscarriage during IVF pregnancy.
What happened during the care of Leona Cusack
The inquest heard that clinical markers for sepsis were present when Leona first presented at University Maternity Hospital Limerick (UMHL) on 15 February and again on 17 February when she arrived at UHL. While a sepsis protocol was initiated at UMHL, the hospital’s handling at UHL became a focal point of the proceedings. A key issue identified by clinicians was a breach of protocol regarding antibiotic administration.
Specifically, it was stated that broad-spectrum antibiotics were not given within the mandated one-hour window; instead, benzylpenicillin alone was administered, described by Dr Cormac O’Connor as an oversight. The coroner and medical witnesses acknowledged this breach as an important factor in the case.
The cardiac complication and the rare diagnosis
The pathologist, Dr. Marcell Szasz, described the cause of death as cardiorespiratory failure due to neutrophilic myocarditis, a very rare condition he has encountered only once or twice in his career. The coroner, John McNamara, noted that the source of infection could not be identified, adding further complexity to an already difficult case for the family and the medical team.
The verdict and the coroner’s conclusions
Mr McNamara explained that he was not satisfied with recording a verdict of death by natural causes, as suggested by the hospital, nor a verdict of medical misadventure. Instead, he delivered a narrative verdict based on the evidence presented over two days of testimony. The coroner emphasised the humanity shown by those involved and the emotional toll on the family and clinicians alike.
Family impact and response
Speaking through their solicitor, Damien Tansey, Leona’s family urged that protocol had not been observed in her treatment at UHL. Mr Tansey commented on the emotional and legal implications of the case, indicating that civil proceedings would be pursued vigorously. Leona’s husband, Conor Cusack, spoke of the profound loss and described his wife as “the loveliest person you could ever meet,” underscoring the personal dimension of the tragedy for the family and their wider circle.
Pregnancy context and hospital transfers
Leona Cusack was five weeks pregnant at the time of presentation following IVF treatment. She initially presented with abdominal and chest pains, shortness of breath, and a concerning metallic taste. While she was reportedly well enough to be transferred between maternity and general hospital services, the inquest highlighted ongoing concerns about the management of her sepsis and the timeliness of antibiotic therapy.
Ongoing investigations and next steps
The coroner, acknowledging the strength of the family’s case for accountability, signaled that civil proceedings may pursue further examination of the hospital’s adherence to sepsis protocols. Clinicians offered apologies for any distress caused by comments made during the inquest, and all involved expressed sympathy for Leona and her loved ones. The inquest closed with a reminder of the complexity inherent in rare medical conditions and in cases where sepsis intersects with obstetric complications.
Why this case matters
Beyond the particulars of Leona Cusack’s case, the proceedings underscore the need for strict adherence to sepsis protocols in maternity and general hospital settings. The narrative verdict reflects a nuanced conclusion that honors the family’s quest for clarity while acknowledging the human dimensions of medical care in high-stakes situations.
