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Lisa Smyth

Inadequate care plan for Orlaith Quinn among an inexplicable list of failings that ended in tragedy

Lisa Smyth


Orlaith Quinn. Credit: Laurence King

Orlaith Quinn. Credit: Laurence King

Orlaith Quinn. Credit: Laurence King

Foreseeable and preventable — two simple words, but they mean so much to the family of Orlaith Quinn.

For five days, the inquest examining the death of the mother-of-three heard details of what can only be described as inexplicable failings in the care she received at the Royal Jubilee Maternity Hospital in Belfast.

The arrival of a new baby should be a joyous time — but unfortunately that isn’t the case for every mum. While baby blues are common, a proportion of women will experience mental ill health in the days, weeks and months after the birth.

For some, it can mean withdrawing from family and friends, difficulty getting washed or dressed, loss of appetite, even an inability to bond with baby.

However, a small percentage of women will go on to develop postpartum psychosis, which is the condition the coroner ruled Mrs Quinn was suffering from when she took her own life.

While it is a medical emergency, Mrs Quinn’s inquest heard from a number of experts who said that not only is it is possible to recover from postpartum psychosis, but patients can improve significantly within a matter of weeks if they receive proper treatment.

This fact alone makes the loss of Mrs Quinn even more difficult to accept.

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Concerns were first raised with staff about Mrs Quinn’s mental state by her mum, Siobhan Graham, after she disclosed she had made three attempts to take her life the previous week.

On the final attempt, she lost consciousness, she said.

Mrs Quinn, who was described by her mum and husband as “manic” and “possessed” at the time, also expressed concerns she had passed negative hormones to her daughter, Meabh, while in the womb.

She was convinced her daughter was disabled as a result of this and her suicide attempts, and that the police were coming to arrest her.

Mrs Graham, who had worked for Women’s Aid for decades and had experience of supporting new mums, suspected her daughter was developing postpartum psychosis and told staff her concerns.

Delivering her findings on Thursday, coroner Maria Dougan said the midwives caring for Mrs Quinn responded properly to her admissions and “escalated their concerns in a timely and appropriate manner”.

Mrs Quinn’s case was appropriately triaged and her mental health assessment was carried out in “a timely manner”, she said.

However, a series of failings from this point, described by Ms Dougan as “a number of missed opportunities in the care and treatment” of Mrs Quinn led to her “foreseeable and preventable” death.

The two members of the psychiatric liaison team who assessed her were singled out for criticism. She said Mrs Quinn should have been spoken to away from her husband, to avoid the possibility that she would withhold the true extent of her illness to stop her husband from becoming upset.

They should have spoken separately to Mr Quinn and Mrs Graham to ascertain their accounts of her mental health, while they should also have read her medical notes ahead of the assessment.

This would have meant they were aware of the comments she had made about her previous suicide attempts, including the fact she had lost consciousness at one stage, while assessing her.

A record of the assessment written by psychiatric nurse John Casey “lacked sufficient detail”, although she said this “did not affect the overall outcome”.

Perhaps one of the most devastating findings, although not overly surprising given the expert evidence that had been presented to the inquest, was that psychiatrist Dr Bob Boggs should have diagnosed Mrs Quinn with postpartum psychosis.

Ms Dougan said this would have happened if he had spoken to, and taken into account, the opinions of Mr Quinn and Mrs Graham. The fact that he was unable to rule out postpartum psychosis meant he should have drawn up a management plan to reflect the possibility Mrs Quinn was severely unwell.

The plan he put in place “lacked detail, used terminology unfamiliar to maternity staff and was inadequate”, said the coroner.

Ms Dougan said Mrs Quinn should have been prescribed medication, moved to a psychiatric ward, or “at the very least” receive one-to-one supervision.

Instead, Dr Boggs recommended a plan of “watchful waiting” and that Mrs Quinn could benefit from a “low stimulus environment”.

She was subsequently moved to a side room, which Ms Dougan said, “prevented ongoing observation” and “offered an easier exit route” from the ward.

Meanwhile, Mrs Quinn and her husband should have been told she may have postpartum psychosis and be provided with a treatment plan. Equally, not all midwifery staff caring for Mrs Quinn overnight were told she may have postpartum psychosis.

And in a further significant finding, Ms Dougan said in light of the differential diagnosis of postpartum psychosis, Mr Casey and Dr Boggs “gave little or no thought to the safety of baby Meabh”.

Ms Dougan also highlighted the need for vastly improved perinatal mental health services in Northern Ireland, in particular calling for a dedicated mother and baby unit to be set up here.

Currently any new mum experiencing a mental health crisis has to be separated from her baby in order to receive inpatient treatment.

Charity Action on Postpartum Psychosis estimates 35 mums will experience postpartum psychosis every year in Northern Ireland.

This figure and the horrific failings that led to Mrs Quinn’s death should be enough to ensure urgent action to protect families across Northern Ireland.

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