The death of a woman who took her own life just hours after a psychiatrist said there was no risk of suicide was “predictable and preventable,” an investigation said.
rlaith Quinn (33) died of 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 came hours after she admitted to family and hospital staff that she had made three suicide attempts less than a week earlier.
Presenting his findings on the tragic case, Coroner Maria Dugan outlined a catalog of devastating failures in the care of Mrs. Quinn in the hours leading up to her death.
She said: “I find, according to the balance of probabilities, the death of the deceased on October 11, 2018 was both predictable and preventable.
Ms. Dugan said that “all available information” in connection with Ms. Quinn’s presentation was received by the psychiatric liaison team, which assessed the mother of three that “the risk of death on October 11, 2018. would be foreseen “.
She continued: “There was a number of missed opportunities in the evidence for me in the care and treatment of the deceased.”
These include failing to conduct a mental health assessment in a private room or one with the word “Do Not Disturb” on the door to prevent staff from entering.
Ms. Dougan also said that psychiatrist Dr. Bob Boggs should have diagnosed Ms. Quinn with postpartum psychosis.
She also found that the management plan he had introduced “was missing and did not address the risk that the deceased was suffering from childbirth psychosis”.
Ms. Dugan also said that the assessment team had to speak to Ms. Quinn alone, without her husband’s presence, and that they had to take a medical history from her husband and mother “separately from the deceased.”
She also found that the remarks made by the psychiatric nurse during the assessment “lacked sufficient detail”, which “may have affected each subsequent management plan of the deceased, but this did not affect the overall outcome”.
Mrs. Quinn died after leaving the side room where she was cared for after the birth of her third child in the early hours of the morning.
She was previously assessed by the psychiatric liaison team of the Belfast Trust after revealing three previous suicide attempts and the fact that she lost consciousness during the last attempt.
Dr Boggs told the investigation that she believed she was suffering from obsessive-compulsive disorder, but could not rule out postpartum psychosis.
However, he did not believe that she posed a risk of suicide and recommended that she be moved to a separate room, and a “vigilant” treatment plan was introduced.
Ms. Quinn disappeared from the room in the early hours of October 11, 2018, after her husband fell asleep.
When he awoke, he found her missing and alerted staff who found her body in a nearby hallway.
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