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Husband welcomes chance to 'be heard' at inquests 37 months after deaths of wife and baby

At times during the hearing at the Dublin District Coroner’s Court this week, Darren Coleman would get up from his seat and quietly leave the room.

The softly spoken teacher from Ballina, Co. Mayo, politely excused himself as the inquest heard details about the death of his wife and baby son. The hearing into the deaths of nurse Nicola Keane, 34, and her seven-month-old son Henry Coleman, who died on October 22, 2020, lasted two days.

Much of the evidence focused on Ms Keane’s battle with post-natal depression and the treatment she received from the Ballyfermot Community Psychiatric Services.

Late on Wednesday night, a jury returned a majority 6-1 verdict of medical misadventure in the case of Ms Keane, who died from polytrauma due to a fall, while a unanimous narrative verdict was returned in baby Henry's case. Ms Keane took her own life after taking the life of baby Henry.

An inquest is often the last chance for families to try and get answers to what happened to their loved ones. When he took the stand, Mr Coleman explained the importance of the inquest and said he had endured a three-year wait to be heard as “the only member of my family alive to speak”.

“No words can describe the pain that I am going through since the death of my wife Nicola and son Henry," he said. “I welcome the jury’s verdict that Nicola’s death was a result of medical misadventure.

“Nicola had severe post-natal depression and postpartum psychosis. I had no idea how sick she was or that there was any risk to her life or our son’s life.

Darren Coleman outside the Dublin District Coroner's Court earlier this week: “Nicola had severe post-natal depression and postpartum psychosis. I had no idea how sick she was or that there was any risk to her life or our son’s life." Picture: Colin Keegan, Collins Dublin
Darren Coleman outside the Dublin District Coroner's Court earlier this week: “Nicola had severe post-natal depression and postpartum psychosis. I had no idea how sick she was or that there was any risk to her life or our son’s life." Picture: Colin Keegan, Collins Dublin

“If I was told how sick she was I would have ensured she received the care she needed to protect both her and baby Henry. I can only hope that lessons have been learned following their deaths."

Receiving a medical misadventure verdict for his wife’s death may have given him some peace. When the foreperson read out the verdicts, Mr Coleman relaxed his shoulders for a moment as he sat waiting for the outcomes.

For two days, he had listened to every word of the evidence intently. The court heard how his wife had suffered severe post-natal depression following the birth of their only baby Henry.

The baby was described as suffering from “irritability” and “persistent crying”. The couple were exhausted, said Mr Coleman during his evidence. Henry was admitted twice to Crumlin Children’s Hospital where doctors could find no reason for his crying. 

He may have been a “colicky baby” said Pediatric Consultant, Dr Una Murtagh, who treated him. However, the second time he was admitted, Nicola told the doctors she felt “no bond” with Henry and she feared she might “do something”.

Although she repeatedly denied any intention of suicide or harming her son. Dr Murtagh said in her evidence that she was “very concerned” about Nicola and held a meeting with other clinicians who all agreed to refer her to adult psychiatric services.

During some of those appointments, which Mr Coleman attended with his wife, he was told not to leave her alone with Henry and described how he often stood outside the bathroom when mum and baby were bathing.

“It completely hurt me to have to monitor the person I had been in a relationship with since I was 17 but I trusted the professionals.” 

Nicola continued to receive treatment and Mr Coleman said he should have been told that his wife’s medication had been increased twice a month before her death. Medical records showed Nicola had “fixed delusional beliefs” and “depressive episodes”.

Mr Coleman, in his evidence, said:

To read about this after their deaths has hurt me so much that I will never recover from it.

The new mother was referred to Dr Elena Perez who reassured the family that one in four women suffered from post-natal depression. Dr Perez said she believed Nicola was “showing signs of improvement” and responding to the medication.

Mr Coleman’s evidence was that there were 12 days when his wife had missed communication from her care team in the run-up to her death. He believed he should have been informed that she had not answered her phone on three occasions during this period.

“If I had been told even one piece of the information being withheld from me, I believe Henry and Nicola would not have died”, he said.

All of the doctors saw a deterioration in Nicola on the child’s second admission. “She had lost weight I was very concerned about her,” Dr Murtagh continued.

But nobody foresaw the end of Nicola’s life in the near future.

She had been settling Henry on the night they died.  He had been crying a lot and Nicola insisted her husband slept and that she would care for the baby. 

In her evidence, Dr Margot Bolster, assistant state pathologist, said Ms Keane died from polytrauma due to a fall from a height and that her death was “instantaneous”.

She said toxicology tests showed no trace of alcohol or drugs in her system and that “she hadn’t taken her medication for a period of time”.

Dr Bolster also carried out a post-mortem examination on baby Henry on October 22, 2020, at Crumlin Children’s Hospital. She said the child had “no injuries” and that “no cause of death could be determined” during the autopsy.

Dr Una Murtagh leaving the Dublin District Coroner's Court earlier this week at  the joint inquest into the deaths of Nicola Keane and her son, Baby Henry. Dr Murtagh said in her evidence that she was “very concerned” about Nicola and held a meeting with other clinicians who all agreed to refer her to adult psychiatric services. Picture: Colin Keegan, Collins Dublin
Dr Una Murtagh leaving the Dublin District Coroner's Court earlier this week at  the joint inquest into the deaths of Nicola Keane and her son, Baby Henry. Dr Murtagh said in her evidence that she was “very concerned” about Nicola and held a meeting with other clinicians who all agreed to refer her to adult psychiatric services. Picture: Colin Keegan, Collins Dublin

However, a toxicology report the following September showed a mixture of two separate medications in the baby’s system.

When the evidence of all parties was finished, the jury made two recommendations, including the building of a postnatal depression programme into the prenatal course for both parents, and said planned mother and baby inpatient units should be created.

Mr Coleman and his sister-in-law left the courts following the verdict, but not before thanking his legal team Rachael Listeon from Listonflavin Solicitors.

In a statement, Rachael Liston told the Irish Examiner: “It is hoped that these verdicts will highlight the need to inform women and their partners of the existence of specialist perinatal mental health services. These services provide specialist mental health care to pregnant woman and for the first year following the birth of their baby."

Mr Coleman said the inquest had taken its toll but that he finally got to speak up for his lost loved ones.

“Today is for me. Today is for Henry. Today is for Nicola.

“And I am the member of my family alive to speak. Finally, 37 months after Nicola was diagnosed with post-natal depression and 35 months after Henry and Nicola’s deaths, my opinion will eventually be heard and listened to."