Overview of the inquest findings
A Clare woman, Leona Cusack (33), died after suffering a miscarriage and a severe sepsis infection that was not treated promptly. The Limerick Coroner’s Court found a breach in the Health Service Executive (HSE) sepsis protocols during her care at University Maternity Hospital Limerick (UMHL) and University Hospital Limerick (UHL). The verdict centered on a delay in administering a broad-spectrum antibiotic regimen, which the inquest concluded may have been lifesaving under the circumstances.
Timeline of events
Ms Cusack, five weeks pregnant after IVF treatment, first presented to UMHL on February 15 after bleeding and abdominal cramps. Blood tests showed indicators suggestive of infection. Despite the sepsis flag raised by a consultant gynecologist, Dr Suhaib Akhtar Birmani, and the order to follow HSE sepsis protocol, the patient did not receive the broad-spectrum antibiotics within the advised one-hour window at UMHL. The couple returned the next day with worsening symptoms, including vomiting and a raised white blood cell count.
On February 17, blood markers for sepsis rose to extraordinarily high levels, and again on February 18 they rose even higher. It was only after these spikes that Ms Cusack was loaded with broad-spectrum antibiotics and transferred to UHL, where she was placed in the coronary care unit under cardiologist Dr Cormac O’Connor. By the evening of February 18, 2024, Ms Cusack had died from cardiac respiratory failure due to neutrophilic myocarditis, a rare condition that can be linked to sepsis or be a source of sepsis itself.
What the evidence showed
Damien Tansey, solicitor for the Cusack family, argued that the delayed administration of the broad-spectrum antibiotics was “too late” and had “no impact” on her deteriorating condition. Multiple medical professionals testified about the care provided, including the obstetric and cardiology teams, and the coroner noted a breach of the sepsis protocol. Dr O’Connor, who oversaw the coronary care unit, became emotional while addressing questions about the care and interactions with Ms Cusack’s sister, Rachael Kirwan, a qualified advanced nurse practitioner. He apologised for any distress caused by remarks made during the discussion about Ms Cusack’s heart condition.
Medical interpretation and verdict
The coroner, John McNamara, described the case as complex and emphasised that the inquiry was a fact-finding exercise. He did not accept a verdict of death by natural causes or death by medical misadventure. Instead, he delivered a narrative verdict, acknowledging the breach in sepsis protocols and the consequent delay in treatment as a factor in the outcome. While the staff involved offered their sympathies, the inquest underscored a critical window in which timely broad-spectrum antibiotics might have altered the result.
Reactions and reflections
Conor Cusack, Leona’s husband, paid a heartfelt tribute: “Leona was the nicest bubbliest person you’d ever meet in your life.” He spoke of the strong bond they shared and the sorrow felt by Leona’s parents and sisters. The family’s response highlighted the emotional toll of the tragedy and the expectation that health systems adhere to established sepsis protocols to prevent similar outcomes in the future.
Implications for policy and practice
The inquest’s narrative verdict draws attention to potential gaps in the practical application of sepsis guidelines within maternity and general hospital settings. Healthcare providers and administrators may review protocol compliance, antibiotic stewardship, and rapid escalation pathways to ensure that suspected sepsis is treated within the recommended timeframe, reducing avoidable delays in critical care.
Conclusion
Leona Cusack’s case serves as a cautionary tale about the deadly consequences of treatment delays in suspected sepsis. While the medical teams involved expressed condolences, the narrative verdict reiterates the need for strict adherence to sepsis protocols to save lives in time-critical situations.
