Overview of the inquest and verdict
A narrative verdict was recorded at the inquest into the death of Leona Cusack, a 33-year-old from Ballycasey, Shannon, Co Clare. Ms Cusack died on 18 February 2024 at University Hospital Limerick (UHL) from cardiorespiratory arrest, following a miscarriage. The two-day hearing examined the care she received after she presented with sepsis-like symptoms while five weeks pregnant.
Timeline and key medical findings
Ms Cusack initially presented at University Maternity Hospital Limerick on 15 February 2024 with abdominal pain, chest pains, shortness of breath and a metallic taste. She was five weeks pregnant following IVF treatment. While her vital signs were stable on admission, she exhibited tachycardia and sepsis was suspected. A sepsis protocol was initiated, with the expectation that broad-spectrum antibiotics would be administered promptly.
At UHL on the morning of 17 February, clinical markers indicated sepsis. However, the inquest heard that broad-spectrum antibiotics were not given until 4pm that day. Doctors acknowledged this delay as a breach of protocol, and questions were raised about whether it affected the outcome. A consultant cardiologist and treating clinicians gave evidence about the breach; one doctor described the initial administration as an oversight, noting that only benzylpenicillin was delivered rather than the broader antibiotic regimen required by the protocol.
Cause of death and expert conclusions
The coroner, Limerick Coroner John McNamara, concluded that the cause of death was cardiorespiratory failure due to neutrophilic myocarditis, a very rare condition. Pathologist Dr Marcell Szasz said he had seen such a condition only once or twice in his career. The source of the infection remained unidentified, and the coroner did not accept a verdict of natural causes as suggested by the hospital, nor a verdict of medical misadventure. Instead, he delivered a narrative verdict based on the evidence presented.
Family impact and responses
The Cusack family, including Leona’s husband Conor and sister, spoke publicly about the emotional ordeal. Solicitor for the family, Damien Tansey, stated that the protocol was not observed in the treatment she received and that a broad-spectrum antibiotic should have been administered within an hour of sepsis being suspected. The family indicated they would pursue civil proceedings “very vigorously” to seek accountability and vindicate Leona’s memory.
In emotional testimony, Conor Cusack described Leona as the loveliest person, saying she was loved by everyone and was a devoted partner, daughter, and sister. The inquest heard from a range of doctors and nurses who offered their sympathies to the Cusack and Kirwan families, with many participants visibly moved by the tragedy.
Clinical reflections and ongoing questions
While the breach of protocol was acknowledged, the coroner emphasized the humanity shown by medical staff during the course of the investigation. The inquest did not establish a definitive infection source, leaving lingering questions about how her infection developed and why it proved so difficult to treat. The case underscores the critical importance of timely antibiotic therapy in suspected sepsis, the potential consequences of protocol deviations, and the complex realities of treating pregnancy-related complications in hospital settings.
What happens next
As indicated by the family’s solicitor, civil proceedings are anticipated. The coroner’s narrative verdict documents the circumstances surrounding Ms Cusack’s death, while the broader medical and legal responses may evolve in light of forthcoming civil actions and further professional reflections on sepsis management in maternity care.
