Euphoric new mum died alone in mental health ward

Sarah Skillington was described as euphoric after giving birth to her first child.

But within two weeks, her mental health had rapidly deteriorated, and she was found dead in the bathroom of a hospital.

Now, a Victorian coroner has found the death of the new mother by suicide after being left unwatched for up to 11 hours on a mental health ward could have been prevented had staff followed their own hospital’s protocol and checked on her every hour overnight.

It was among several damning findings made by coroner David Ryan following a five-day inquest earlier this year into the death of Skillington.

The 33-year-old architect from Bentleigh died at Mitcham Private Hospital’s Perinatal Mental Health Unit less than two weeks after giving birth to her daughter at Frances Perry House on November 6, 2023.

“Sarah’s death was a tragedy which is devastating to her family and friends,” Ryan said. “The inquest was a necessary but challenging and distressing process for both her family and clinicians.”

Ryan detailed a cascade of failures in Skillington’s care and said fundamental aspects of her treatment had been “significantly undermined”.

This included a failure by staff to observe her each hour overnight, which allowed her to enter the bathroom undetected and take her own life.

The coroner also found that Skillington had been wrongly diagnosed with anxiety when she was instead in the grips of postpartum psychosis, despite being assessed by a psychiatrist as being low risk and placed on category 1 observations.

Ryan also criticised the fact that only one nurse was left to monitor six patients overnight, and slammed a lack of mental health training among staff in the perinatal unit, including an absence of expertise on how to diagnose and respond to postpartum psychosis.

He made several sweeping recommendations for Ramsay Health Care, which oversees Mitcham Private Hospital, including that it increase minimum staffing levels to two clinicians at all times inside the perinatal mental health unit, with at least one having mental health training and experience.

Ryan also said the health service must provide specific training to nursing staff in the perinatal mental health unit on how to recognise and treat postpartum psychosis, which can be difficult to distinguish from postnatal anxiety.

“There is no evidence that nursing staff of the unit receive specific and targeted training in relation to recognising the signs and symptoms of postpartum psychosis,” Ryan said.

The new mother was described as “euphoric” following the birth of her baby girl, but her mental state rapidly plummeted in the days that followed as she desperately sought help from several doctors before being found unresponsive in the mental health ward.

The coroner had been told that the day after Skillington gave birth, she became anxious and raised this with her obstetrician, Philippa Costley, who asked the hospital to keep her in an extra night.

Skillington was released on November 11, and went to see a GP the following day, who referred her to Mitcham Private Hospital.

“Very bad anxiety post-natal,” the GP’s notes read. “Overwhelmed, feeling she cannot cope, had the good support of partner. Priority referral please ASAP.”

Costley, who broke down during her evidence to the inquest, said she grew so concerned about systemic delays in getting her patient psychiatric care that she came up with a back-up plan, reaching out to a psychiatrist to help manage Skillington until she could get a bed in a hospital.

During an appointment on November 14, Costley observed Skillington appeared flat and dishevelled and urged her to go to the mothers and babies hospital ward.

When Skillington arrived there on November 16, she was assessed as low risk and would be monitored every two hours. She was found dead on the morning of November 19.

The inquest previously heard evidence from a nurse who said she had conducted observations of Skillington between 7am and 8am the morning she was found dead.

She said she did not check for signs of life and observed her, through a window that looked into the hospital room, to be sleeping in bed.

This went against instructions which require staff to examine patients for signs of life.

Ryan said the last time Skillington could be confirmed to have been alive was when her partner, Jarvis Johnson, saw her at 10.27pm on November 18.

Ryan said Skillington was deeply loved by her family and friends, and her death had left them grappling with profound grief and devastation.

“They painted a vibrant and affectionate picture of a remarkable woman who embraced life and was dearly loved by those around her,” he said.

In a statement, Ramsay Health Care said several investigations were initiated following Skillington’s death, including a Root Cause Analysis and inquiries by WorkSafe Victoria.

“We have taken proactive steps to implement all recommendations from the Root Cause Analysis to ensure we provide ongoing safe and effective treatment for the women in our care,” the statement read.

“We will carefully review the recommendations from the coroner. We extend our deepest condolences to Sarah’s family and friends for their devastating loss.”

Lifeline: 13 11 14

With Erin Pearson

The Morning Edition newsletter is our guide to the day’s most important and interesting stories, analysis and insights. Sign up here.