Inquest finds a culture of noncompliance at specialist mental health unit for new mums, after nurses failed to conduct hourly checks
The husband of new mum Sarah Skillington — who admitted herself to Mitcham Private Hospital’s perinatal mental health unit — feels tormented by guilt for not staying the night after hourly checks were not performed by nurses, and she took her own life.
Victoria
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A culture of noncompliance had developed at a specialist mental health unit for new mothers after nurses failed to conduct hourly checks on a woman who took her own life, a coroner has found.
Sarah Skillington, 33, died by suicide at Mitcham Private Hospital’s Perinatal Mental Health Unit after she was admitted with post-partum anxiety less than two weeks after giving birth to her daughter Lily in late 2023.
An inquest into the Bentleigh mother’s death heard an overnight nurse failed to check on her for up to 11 hours before she was found dead in her room shortly before 9am on November 19.
Hospital protocol required hourly checks to be conducted overnight but she was last seen alive by staff about 10pm.
Delivering his findings on Wednesday, Victorian coroner David Ryan said a culture of noncompliance appeared to have developed among staff, particularly those on night shift, noting there were instances where inaccurate entries had been made on observation charts.
However the coroner said he could not conclude that the checks would have prevented her death and she may have taken her life in the intervening period.
Ms Skillington had not disclosed suicidal thoughts and had been classified as low risk, with staff also reporting they did not observe a change in her mental state that warranted escalating her care.
An expert report prepared for the coroner found the staffing level in the unit, which included a single overnight nurse, was “inadequate and unsafe”.
Mr Ryan said there was “no evidence” that staff had received training to recognise the symptoms of postpartum psychosis, which Ms Skillington likely had, and most did not have mental health qualifications.
He recommended Ramsay Health Care, which operates Mitcham Private Hospital, provide specific training relating to post-partum psychosis and require two nurses to be rostered on duty at all times to promote peer review and good practice.
During the five-day inquest in February, Ms Skillington’s mother Karen Skillington said Mitcham Private Hospital had failed her daughter in her most vulnerable moment.
“I feel cheated and devastated by her death which occurred due to the inadequate care provided to her when she was at her most vulnerable,” she said.
Ms Skillington’s husband Jarvis Johnson, who closely supported and cared for his wife after she gave birth, said he’d been tormented by guilt at leaving her alone in hospital the night of her suicide.
The inquest heard Ms Skillington had been delighted at the arrival of her daughter Lily but soon developed post-partum anxiety which spiralled and prompted her voluntary admission to the clinic specialising in the care and supervision of clinically-depressed new mothers.
A suicide note was found at her home after her death, expressing her love to her husband Jarvis and Lily and regret for being her unable to escape her suffering.
Ms Skillington was a talented architect known for her work in Australia and the USA.
Mr Ryan said impact statements from her family conveyed their grief and devastation from her passing.
“They painted a vibrant and affectionate picture of a remarkable woman who embraced life and was dearly loved by those around her,” he said.
The court previously heard WorkSafe was considering laying criminal charges against those involved in the tragedy.
In a statement, Ramsay Health Care expressed its condolences to Ms Skillington’s family and said it had offered to meet with them if they wished to discuss the findings.
“Several comprehensive investigations were initiated following Sarah’s death including a Root Cause Analysis (RCA) and inquiries by Work Safe Victoria and the Victorian Coroner,” they said.
“We have taken proactive steps to implement all recommendations from the RCA to ensure we provide ongoing safe and effective treatment for the women in our care. We will carefully review the recommendations from the Coroner.
“The safety and wellbeing of our patients and people remains our highest priority.”
Family members of Ms Skillington were present in court on Wednesday, including her husband.
Mr Ryan thanked them for their patience during the coronial process.
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