The death of a woman who took her own life just hours after a psychiatrist said she was not a suicide risk was “foreseeable and preventable”, an inquest has found.
Orlaith Quinn (33) died by suicide at the Royal Jubilee Hospital (RJMH) in Belfast in the early hours of October 11, 2018, less than two days after the birth of her daughter, Meabh.
Her death occurred just hours after she admitted to her family and staff at the hospital that she had made three suicide attempts less than a week before.
Delivering her findings into the tragic case, coroner Maria Dougan outlined a catalogue of devastating failings in the care of Mrs Quinn in the hours leading up to her death.
She said: “I find, on the balance of probabilities, the deceased’s death on October 11, 2018 was both foreseeable and preventable.”
Ms Dougan said “had all of the available information” in relation to Mrs Quinn’s presentation been obtained by the psychiatric liaison team who assessed the mother-of-three, that “the risk of the deceased’s death on October 11, 2018, would have been foreseen”.
She continued: “In the evidence to me, there were a number of missed opportunities in the care and treatment of the deceased.”
Among these was a failure to carry out the mental health assessment in a private room or one with a ‘do not disturb’ sign on the door to prevent staff from entering.
Ms Dougan also said psychiatrist Dr Bob Boggs should have diagnosed Mrs Quinn with postpartum psychosis.
She also found the management plan he put in place “was lacking and did not adequately address the risk the deceased was suffering from puerperal psychosis”.
Ms Dougan also said the assessment team should have spoken to Mrs Quinn on her own, without her husband present, and that they should have taken a history from her husband and mum “separately from the deceased”.
She also found the notes taken by the psychiatric nurse during the assessment “lacked sufficient detail”, which “may have affected any subsequent management plan for the deceased, however, this did not affect the overall outcome”.
Mrs Quinn died after leaving the side room where she was being cared for after the birth of her third child in the early hours of the morning.
She had earlier been assessed by the Belfast Trust’s psychiatric liaison team after revealed three previous suicide attempts and the fact she had lost consciousness during the final attempt.
Dr Boggs told the inquest he believed she was suffering from obsessional neurosis but could not rule out postpartum psychosis.
Despite this, he did not believe she was a suicide risk and recommended she be moved to a private room and a treatment plan of “watchful waiting” was put in place.
Mrs Quinn went missing from the room in the early hours of October 11, 2018, after her husband fell asleep.
When he woke, he discovered she was gone and alerted staff who found her body in a nearby corridor.