Sarah gave birth to a healthy baby girl. Less than two weeks later, she died in a mental health ward
By Erin Pearson
A new mother who died within days of being admitted to a mental health ward for anxiety was left unwatched for up to 11 hours, in breach of hospital protocol, before she was found unresponsive.
Day one of a coronial inquest into Sarah Skillington’s unexpected death heard the 33-year-old gave birth to a healthy girl named Lily on November 6, 2023, and appeared excited about the future.
A coroner is investigating the death of new mum Sarah Skillington.
When she developed anxiety shortly after the birth, her doctor recommended she be admitted to Mitcham Private Hospital’s perinatal mental health ward for extra support.
But counsel assisting the coroner, Megan Fitzgerald, said that within three days of arriving at Mitcham, Skillington was found dead in her room, after potentially being left alone for up to 11 hours.
“There may have been shortcomings in the care provided and the facility [and] potential findings that one or more of these contributed to Sarah’s death,” Fitzgerald said.
The coroner was 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 the 33-year-old 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 grew so concerned about systemic delays in getting her patient psychiatric care that the obstetrician 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, having died by suicide.
Sarah Skillington was found dead in her hospital room after being admitted for severe anxiety after giving birth.
Fitzgerald said doubts have since been raised about the accuracy of observation charts, the quality of care she received and the training and adequacy of staff at the private hospital.
There was also uncertainty around when exactly Skillington died as it appeared no one had checked on her for up to 11 hours overnight.
“She was delighted as Lily was born. She was extremely engaged with Lily. It was a really happy birth,” Costley said.
Costley said that on November 10, she became concerned that difficulties breastfeeding might have been contributing to her patient’s anxiety and ordered all breastfeeding equipment in the room be removed.
“I told her she doesn’t have to breastfeed,” she said. “We see many women have significant anxiety in this period, that over a few days does start to settle.
“When I found out she had a bed, I was relieved. I felt she needed psychiatric care. That’s something as an obstetrician I can’t provide.”
Costley sobbed as she recalled the last time she spoke to Skillington.
“She called me from the hospital and she said [she] did not want to be there. I told her she needed to stay there and she wasn’t OK,” Costley said.
The coroner was told a “significant” number of witnesses set to provide evidence over the coming week had asked for certificates that would offer protection from criminal or civil prosecution regarding what they might say.
Those following the inquest on Monday included Skillington’s husband, Jarvis Johnson, parents Peter and Karen Skillington, and brother Rob.
The inquest continues.
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