THE death of a woman who died by suicide in hospital could have been prevented, a coroner has found.
Orlaith Quinn (33), from Lagmore near Dunmurry, died in the early hours of October 11 2018 at Belfast's Royal Jubilee Maternity hospital - two days after she gave birth to her third child.
In a hard-hitting verdict yesterday, coroner Maria Dougan found that Mrs Quinn's death was "both foreseeable and preventable".
Orlaith Quinn death: Specialist mental health mother and baby unit badly needed
Ms Dougan found that Mrs Quinn was suffering from postpartum psychosis at the time of her death.
The mother of three children - Conal, Aodhan and Meabh - Mrs Quinn was not deemed to be a suicide risk by the psychiatrist who saw her.
However, she told her family and medical staff that she had attempted suicide three times before the birth of her daughter.
Her husband Ciaran Quinn previously told the inquest that his wife initially bonded with their daughter.
But he said she subsequently became "manic, uncontrollable and exploding with all kinds of emotion".
Mrs Dougan said psychiatrist Dr Robert Boggs should have diagnosed Mrs Quinn with postpartum psychosis "and he would have done so had he taken a fuller collateral history".
Speaking after the verdict, Ciaran Quinn said the inquest confirmed what the family already suspected.
"Most importantly, the verdict has confirmed that Orlaith would not have died on the night in question and would have fully recovered from the illness from which she was suffering," he said.
"Had my wife received the appropriate care she would still be alive today.
"We now expect a full and frank apology from the Belfast Trust and for them to accept accountability and responsibility for Orlaith's death.
"We love you and miss you more than any words can ever describe."
Mrs Quinn's mother Siobhan Graham said the family "lost our lives with Orlaith that day, part of us died when Orlaith died".
She said a "lack of care" led to her daughter's death.
"Women are put out of maternity units six hours after giving birth and then we wonder why professionals who are in the game for 35 years have never seen a case of postpartum psychosis," she said.
In a statement, the Belfast Trust said: "Belfast Trust would like to extend a sincere and unreserved apology to the family of Mrs Orlaith Quinn".
"We know this continues to be an incredibly painful time and we offer our deepest sympathies to them."
The inquest heard Dr Boggs, who assessed Mrs Quinn, had a working diagnosis of "obsessional neurosis" and a "differential diagnosis of postpartum psychosis".
Ms Dougan said had the mother-of-three been primarily diagnosed with postpartum psychosis, or had a better risk management plan been carried out, her death could have been prevented.
She said Mrs Quinn should have been given medication, transferred to a psychiatric ward or "at the very least" put under one-to-one observation until a further psychiatric assessment was carried out.
And she said Dr Boggs and psychiatric nurse John Casey "gave little or no thought" to the safety of Mrs Quinn's newborn baby daughter and did not include her in any management plan.
She outlined a litany of "missed opportunities" to help Mrs Quinn including:
:: The management plan Dr Boggs initiated was "lacking", "inadequate" and did not address the risk of postpartum psychosis
:: The mental health assessment of Mrs Quinn, which was interrupted four times, should have been held in a private room
:: Mrs Quinn should have been assessed on her own, without her husband Ciaran present
:: Her mental health history was incomplete and histories should have been taken from her husband and mother separately
:: Dr Boggs and Mr Casey should have read Mrs Quinn's maternity notes rather than relying on a verbal handover
:: Dr Boggs should have provided a full handover to midwifery staff once he had completed his notes
:: Mr Casey should have provided a psychiatric risk assessment document immediately after the mental health assessment
:: Mrs Quinn should not have been moved to a side room where midwives could not see her from their nursing station
:: Mrs Quinn and her husband should have been properly informed about how her illness was to be managed
:: Handovers between midwifery staff were not sufficient
:: A risk assessment should have been completed for Mrs Quinn's newborn daughter
Ms Dougan also recommended that a specialist mental health mother and baby unit should be set up in Northern Ireland.
"The deceased's death highlights the need for obstetric wards to have much closer links with perinatal services," she said.
The inquest heard that since Mrs Quinn's death some medical staff at the Trust had received training in postpartum psychosis.
However, the rollout of the training had been affected by the pandemic.
The coroner said she hoped that the Belfast Trust had learned important lessons from the case.