Overview of the case
A coroner’s inquest in Limerick has determined that a breach of the Health Service Executive (HSE) sepsis protocol contributed to the death of Leona Cusack, a 33-year-old woman from Co Clare. After suffering a miscarriage and presenting with signs of sepsis, Ms Cusack was not given the prescribed broad-spectrum antibiotics promptly, and her condition deteriorated rapidly.
Timeline of events
Ms Cusack first presented at University Maternity Hospital Limerick (UMHL) on February 15, 2024, when she was five weeks pregnant following IVF treatment. She experienced bleeding and abdominal cramps and underwent initial blood tests. On February 16, her condition worsened with vomiting and a raised white blood cell count, prompting her to return to UMHL. A consultant gynecologist, Dr Suhaib Akhtar Birmani, flagged a possible sepsis infection and ordered the HSE sepsis protocol.
Despite the recommendation to administer a broad-spectrum antibiotic within one hour, the appropriate medication was not given at UMHL. On February 17, after further deterioration and rising sepsis markers, Ms Cusack was admitted again to UMHL and then transferred to University Hospital Limerick (UHL) in a more critical state, where she was placed in the coronary care unit under a cardiologist’s care, Dr Cormac O’Connor.
At UHL, Ms Cusack’s blood tests showed “extraordinarily high” markers for sepsis, followed by “doubly extraordinarily high” levels on February 18. However, the broad-spectrum antibiotics were not initiated in time, and by the evening of February 18 she had died from cardiac respiratory failure due to neutrophilic myocarditis, a rare condition that can be linked to sepsis.
Professional responses and courtroom findings
Damien Tansey, solicitor for Ms Cusack’s family, described the antibiotic loading on February 17 as “too late” and without meaningful impact on her prognosis. The coroner, Mr. John McNamara, emphasized that the inquest was focused on fact-finding and delivered a narrative verdict, noting a breach of the sepsis protocol. He stressed that the case was complex and that the objective was to understand what occurred rather than assign simple fault.
During testimony, Dr Cormac O’Connor, the cardiologist at UHL, acknowledged the breach but disputed the claim that sepsis care was ignored. He stated that Ms Cusack was ultimately escalated with antibiotics, but the timing did not alter the fatal outcome in his view. He also offered condolences to the family and later expressed regret for any distress caused by comments to Ms Cusack’s sister, who is a qualified nurse practitioner.
Impact on families and public health implications
The inquest heard from Ms Cusack’s husband, Conor Cusack, who spoke of her as “the nicest, bubbliest person you’d ever meet.” Her family described a life cut short and a system that, in their view, failed to act swiftly in a critical window for sepsis treatment. The verdict and testimony raise questions about adherence to sepsis protocols across facilities and the need for vigilant implementation of guidelines to prevent delays in antibiotic administration.
Moving forward
This case serves as a stark reminder of the importance of timely sepsis management. Hospitals and health authorities may review protocol adherence, staff training, and the mechanisms to escalate care quickly when sepsis is suspected. For families affected by sepsis-related tragedies, ongoing advocacy remains essential to improve responses in emergency and maternity settings and to reduce preventable losses.
