Inquest touching upon the death of Orlaith Quinn
| Jurisdiction | Northern Ireland |
| Judge | Miss Dougan |
| Judgment Date | 26 May 2023 |
| Neutral Citation | [2022] NICoroner 13 |
| Court | Coroners Court (NI) |
Neutral Citation No: [2022] NICoroner 13
Judgment: approved by the Court for handing down
(subject to editorial corrections)*
Ref: 2022NICoroner 13
Delivered: 26/05/2022
CORONER FOR NORTHERN IRELAND
CORONER MARIA DOUGAN
THE INQUEST TOUCHING UPON THE DEATH OF
ORLAITH QUINN
Introduction
1. The inquest proceeded in hybrid form, meaning that a mix of remote
technology and live courtroom attendance was utilised. The case proceeded in a
socially distanced court in Laganside Courts, Belfast, between 9 and 13 May 2022.
During the inquest, I received evidence from a number of witnesses and I considered
a number of statements admitted under Rule 17, together with voluminous hospital
notes and records. It is not possible to recite all of the evidence in these findings,
although all of the evidence has been considered before arriving at these findings.
Evidence
2. The Deceased Orlaith Quinn, born on 29 April 1985, at an address in Belfast,
died on 11 October 2018.
3. Mr Ciaran Quinn, husband of the Deceased gave evidence to the inquest. He
told the inquest that they had been together for 17 years and had three children
together. Their third child was born at 09.23 hours on 9 October 2018.
4. Mr Quinn described how their first two children had been born by caesarean
section and he felt the entire experience was “very traumatic” for the Deceased.
After the births of their first two children, he stated the Deceased’s mood dipped.
After their second child was born the Deceased was prescribed sertraline by her GP
which she stopped taking shortly after as “it made her feel worse” and “it just didn’t
agree with her”. After a short time, he said, “she got back to herself”. Mr Quinn
stated that the Deceased suffered from slight anxiety at certain times but did not
suffer from depression.
5. Mr Quinn told the inquest that at around 29 weeks, the Deceased found out
that, Baby A was in breech position and that she would have to be born by caesarean
section. He said she always wanted a natural birth. Mr Quinn explained that there
was a stark difference from the first half of her pregnancy when “she was loving,
warm and excited” and then the Deceased’s mood “drastically changed” and she
became withdrawn and “lost an edge to her personality”. In the last six weeks of the
pregnancy, Mr Quinn continually asked what he could do to help and the Deceased
replied that, “she will be better when the baby is here”. Around this time, she was
also affected by her grandmother’s cancer diagnosis, the stress of applying for two
jobs and her son not settling at school. Mr Quinn described how the Deceased had
become withdrawn and worried. She had not been speaking to her friends as much
as she used to and stopped wearing make up in the last month of her pregnancy. He
put the Deceased’s feelings down to nervous energy and he stated that he was “not
hugely worried” about the Deceased’s mental health as she kept reassuring him.
6. When Baby A was born on 9 October 2018 Mr Quinn described how happy
the Deceased was and how she initially breastfed her baby which he described as
“wonderful”. It brought him great relief to see the Deceased bonding with the baby.
Later, the Deceased had to bottle feed Baby A, commenting, “I cannot even feed that
baby properly”. This frustrated the Deceased and she became quite irritable and on
edge. When he left to go home that night he described the Deceased as seeming
perfectly calm.
7. On 10 October 2018, Mr Quinn arrived on E Ward to visit the Deceased and
their newborn baby. He told the inquest that he brought the Deceased some food,
which she took one bite of and then discarded. In the afternoon, Mr Quinn asked the
Deceased to lie down in bed to sleep as she looked extremely tired. He described
how the Deceased put her head on the pillow but then jumped up immediately. Mr
Quinn told the inquest that what happened next was something he had never seen in
the 17 years he had been with the Deceased. He said that the Deceased was “manic,
uncontrollable, loud, speaking irrationally, would not listen to reason, she was
“angry, upset and physically shaking”. He went onto to say “she became extremely
manic, she exploded with all these different emotions” and it was “almost like she
was possessed by someone else”.
8. The Deceased told Mr Quinn that there was something wrong with their
baby, that Baby A was disabled, “not right”, and that “she was going to need a
wheelchair”. Mr Quinn told the inquest that the Deceased kept saying the police
were coming for her and that she was going to jail. The Deceased then told Mr
Quinn that she tried to kill herself on Friday 5 October 2018 at home with the belt of
her dressing gown. She stated that she tried to do it three times and on the third
attempt, she lost consciousness but was not sure for how long and was convinced
the baby had been deprived of oxygen.
9. Mr Quinn told the inquest that he was in total shock at the Deceased’s words
and how she was presenting physically. He said he tried to assure her that the baby
was fine and he tried to calm her down as she was shouting. He said he was afraid,
as that was not the “Orlaith he knew and loved”. The Deceased told Mr Quinn that
she felt worthless and useless. Mr Quinn stated he could tell that she was extremely
unwell. He telephoned the Deceased’s mother, Mrs Siobhan Graham, and explained
that something was wrong with the Deceased and that she needed to return to the
hospital immediately.
10. Before the Deceased’s mother returned, Mr Quinn described how the
Deceased was still speaking irrationally and becoming angry when he was telling
her that the baby was fine and healthy. The Deceased stated that all the anxiety she
had and other negative thoughts and feelings had now passed to Baby A and she
had ruined the baby’s life. Mr Quinn stated that the Deceased was convinced that
her stress hormones had transferred to the baby.
11. When the Deceased’s mother arrived, the Deceased repeated everything she
had told Mr Quinn. Mrs Graham then spoke with the nursing staff and she
described how the Deceased was behaving.
12. Later that afternoon, the Deceased and Mr Quinn were taken into an office on
the ward to speak to two members of the Psychiatric Liaison Team, Dr Robert Boggs,
Associate Specialist Psychiatrist and Mr John Casey, Liaison Psychiatry Nurse. Mr
Quinn stated that there were at least four interruptions during the assessment while
the Deceased was answering questions. The door kept opening with staff trying to
access the room. He could see that the Deceased was becoming visibly frustrated
and agitated at the interruptions. He described how her bottom lip was trembling
and eyes were constricted.
13. Mr Quinn described the assessment as more of an overview and that they did
not “delve deep enough into what Orlaith was going through”. Mr Quinn described
how Nurse Casey was unable to keep up with the simple detail the Deceased was
providing and that this unsettled the Deceased as she was constantly repeating her
responses. Mr Quinn told the inquest that he believed this led the Deceased to lose
faith in Dr Boggs and Nurse Casey and the assessment process.
14. Mr Quinn told the inquest how the Deceased provided all the detail about
how she attempted to take her own life and how she had lost consciousness and then
she had fear that “she had brain damaged Baby A and starved her of oxygen”. He
said she mimicked how she did it “to get the point across”. She had to correct them
several times on the details they recorded. She told them in the week and days
before her scheduled caesarean section she could not sleep and was downstairs
crawling around the living room, sweating, full of anxiety, in extreme mental pain
and how she felt that her increased cortisol levels and stress affected her baby. Mr
Quinn stated that was the first he had heard of this and that “she kept it all from
me”. He said, “the more worried Orlaith became the less she told me”. The
Deceased went on to say that, she blamed herself for her son, not settling in school
and that she felt huge guilt about this.
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