Case Studies: Healthcare

Inquest into the Death of Orlaith Quinn – “Foreseeable and Preventable”

Orlaith Quinn, mother of three and wife to Ciaran Quinn, was 33 years old when she died on 11 October 2018, at the Royal Jubilee Maternity Hospital.  Patrick Mullarkey of O’Reilly Stewart solicitors acted on behalf of the family of Orlaith Quinn at the inquest.

On Thursday, 26 May 2022 the Coroner, Maria Dougan,  found that Orlaith’s death was both “foreseeable and preventable”. Orlaith took her life less than two days after the birth of her third child, when the balance of her mind was disturbed by reason of postpartum psychosis. Earlier a psychiatrist had incorrectly determined that Orlaith was not a suicide risk.

The Coroner detailed failures on the part of the Belfast Health and Social Care Trust in the care provided to the deceased. She determined that had all of the available information in relation to Orlaith’s presentation been obtained by the psychiatrist prior to and during the mental health assessment, then Orlaith’s death would have been foreseen. The coroner found that had the deceased been correctly diagnosed with postpartum psychosis as a primary diagnosis or, at the very least, an appropriate risk management plan taking account of the differential diagnosis of postpartum psychosis, been drafted and implemented, Orlaith’s death was preventable.

In so finding, the coroner identified a litany of “missed opportunities” in the care and treatment of the deceased including; the circumstances in which the mental health assessment was conducted, the adequacy of the mental health assessment , the taking of a collateral history from family members who were in a position to provide relevant and germane information, the diagnosis of the patient, the communication of that diagnosis to the patient, family and nursing staff, the planning of care on foot of the diagnosis and the physical arrangements made for such care when planned. Had all of these matters been attended to then Orlaith would inevitably been correctly diagnosed, her care would have ensured her safety in the interim and she would have been expected to recover from an entirely treatable condition.

In a statement by Ciaran Quinn in the wake of the coroner’s verdict, he said;

It has been over 3 and a half years since we lost my beautiful wife Orlaith, for each and every day since, we have strongly believed that Orlaith was failed by the very people who were supposed to care for her. We believe she did not receive the care, protection or treatment that her illness so badly demanded.

Today was truly Orlaith’s day, because she finally got the truth that she deserved.

The verdict given today by Madame Coroner Dougan has confirmed and validated our belief. The verdict has shown that the entire management of Orlaith during the course of her postnatal care was substandard. From referral, to assessment, to diagnosis, to care planning and to the institution of that care, there were deficiencies, mistakes and failures.

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. Had my wife received the appropriate care, we would still have her today.

We now expect a full and frank public apology from the Belfast trust and for them to accept accountability and responsibility for Orlaith’s death.

It is our hope that Orlaith’s death was not in vain. We so badly hope that Belfast trust implements real and meaningful changes to their perinatal mental health care procedures, that prevent any more women losing their lives so needlessly and in such catastrophic circumstances and that no other family are faced with the devastating realty that we live every day and will continue to live with forever.

To Orlaith, we love you and miss you, I promise to do everything I can to make you proud and raise our children in the way you had always hoped to do. We will never ever forget you x

In a call to action, to prevent similar deaths in future, the Coroner called for Mother and Baby Unit to be established in Northern Ireland and, at the very least,  for the rapid expansion of perinatal services within the hospital setting as well as in the community. She noted that Orlaith’s death highlights the need for obstetric wards to have much closer links with perinatal services.

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