Overview of the Inquest and Verdict
A narrative verdict was recorded at the inquest into the death of Leona Cusack, a 33-year-old woman from Ballycasey, Shannon, Co Clare. Ms Cusack died at University Hospital Limerick (UHL) on 18 February 2024, one day after a miscarriage during IVF treatment. The inquest, which spanned two days, examined the medical care she received after she presented with symptoms that suggested sepsis. The coroner, Limerick’s John McNamara, concluded with a narrative verdict rather than a verdict of natural causes or medical misadventure, reflecting the complex and contested medical circumstances of the case.
The Medical Facts and Markers
The inquest heard that clinical markers for sepsis were present when Ms Cusack arrived at UHL on the morning of 17 February. Despite this, broad spectrum antibiotics were not administered until 4pm. Doctors acknowledged this delay breached established sepsis protocols, which normally require timely initiation of broad spectrum antibiotics to combat suspected sepsis.
Initial Presentation and Suspected Sepsis
Ms Cusack was five weeks pregnant following IVF treatment when she first presented at University Maternity Hospital Limerick (UMHL) on 15 February with abdominal pain, chest pains, shortness of breath, and a strange taste in her mouth. Her condition prompted a sepsis protocol at UMHL, and concerns for her pregnancy prompted careful monitoring as she was transported to UHL for further care. Although her vital signs were initially reported as stable, tachycardia indicated stress on her heart, and sepsis remained a central concern throughout the course of her care.
The Role of the Cardiorespiratory and Cardiac Findings
The post-mortem findings identified cardiorespiratory failure due to neutrophilic myocarditis as the cause of death—a rare condition that pathologist Dr Marcell Szasz said he has encountered only once or twice in his career. This diagnosis points to a severe inflammatory process in the heart that contributed to the fatal outcome. The coroner noted that the source of the infection could not be identified, leaving questions about how sepsis began and progressed in this case.
Responsibility, Protocols, and the Verdict
Coroner John McNamara stated he was not satisfied with recording a verdict of death by natural causes as proposed by the hospital, nor with a verdict of medical misadventure. Instead, he delivered a narrative verdict that framed the case around the evidence presented and the broader context of care. He cautioned that the inquest did not assign sole fault but highlighted procedural shortcomings in the treatment timeline.
Key Protocol Breach
Solicitor for the family, Damien Tansey, underscored that the sepsis protocol required broad spectrum antibiotics to be administered within an hour of suspicion. The evidence indicated that only benzylpenicillin, a narrow-spectrum antibiotic, was given initially—an omission described by the treating consultant as an oversight. The family’s representatives argued that this breach was a critical factor in the deterioration of Ms Cusack’s condition.
Reactions and Aftermath
Outside the courtroom, the Cusack and Kirwan families spoke about Leona as a beloved wife, sister, daughter, and friend. Her husband, Conor Cusack, described her as “the loveliest person you could ever meet,” and expressed intent to pursue civil proceedings “very vigorously.” The inquest process was marked by empathy from medical staff who expressed condolences for the loss of a young life and the hopes that Ms Cusack carried for her pregnancy and future family life.
What Comes Next?
The inquest highlighted the ongoing need for rigorous adherence to sepsis protocols, even in difficult clinical scenarios. While the cause of death was established as cardiorespiratory failure due to neutrophilic myocarditis, the unanswered questions about the infection source and timing of antibiotic administration leave room for continued scrutiny of care pathways and potential civil action by the family. The verdict underscores the importance of timely intervention in suspected sepsis, especially in pregnancies complicated by IVF and early-term loss.
Family Reflections and Support
Family members emphasized the humanity shown by clinicians and staff during the two-day hearing, acknowledging the emotional toll of the case. The coroner’s remarks about the “lot of humanity” seen throughout the inquest contrasted with the distress surrounding the medical decisions and outcomes, a reminder of the human dimension behind every clinical protocol and policy.
