The death of a young mother in any circumstances is an enormous tragedy for her family and in particular the children she leaves behind.
But the death by suicide of Orlaith Quinn within a hospital setting, just two days after giving birth, also raises serious questions for our health service.
The 33-year-old was being cared for at Belfast's Royal Jubilee Maternity hospital when she took her own life in October 2018.
The coroner found that at the time of her death the mother-of-three had been suffering from postpartum pyschosis, a serious mental illness that can occur soon after having a baby. However, she was not deemed to be a suicide risk by the psychiatrist who saw her.
An inquest examined the circumstances of her care in detail and revealed a litany of missed opportunities.
Orlaith had told family and medical staff that she had attempted suicide three times but a management plan for her was described as inadequate.
In a damning verdict, coroner Maria Dougan found that her death had been "both foreseeable and preventable".
Mrs Quinn's grieving husband Ciaran called for a full apology from health authorities, saying his wife would still be alive had she received the appropriate care.
Importantly, Ms Dougan recommended that a specialist mental health mother and baby unit should be set up in Northern Ireland.
The case has shone a spotlight on a little known but serious condition that can strike women at a time when they are most in need of support.
Postpartum psychosis affects around 1 in 500 mothers after giving birth. Around half will have experienced no previous mental illness and early intervention can help lead to a full recovery.
The NHS says it should be treated as a medical emergency and charities have called for improved awareness amongst health professionals and the general public.
The group Action on Postpartum Psychosis is also setting up a peer support network to help mothers who have experienced mania or psychotic symptoms.
Ms Dougan said Orlaith's death has highlighted the need for obstetric wards to have much closer links with perinatal services.
More generally, it should spark debate about the speed with which new mothers are discharged from maternity units and the arrangements in place in the challenging days and weeks afterwards.
Health authorities should make a commitment that the death of Orlaith Quinn will be the last from postpartum psychosis. Honouring her memory would require nothing less.
