Source : Perth Now news
Hospital staff failed to properly check on a new mum in the grips of postpartum psychosis, but her suicide may not have been preventable, a coroner has found.
Sarah Skillington was last seen alive by her husband at 10.27pm as he left her room at the perinatal unit in the Ramsay Health Care-owned Mitcham Private Hospital, in Melbourne’s east, on November 18, 2023.
The 33-year-old was discovered unresponsive more than 10 hours later and declared dead.
Coroner David Ryan found the overnight nurse did not conduct hourly observations as required and it appeared a “culture” had developed among some night-shift staff that meant checks were not done appropriately.
A suicide note was found at her home in the days after her death and the coroner said the message was likely written before she was admitted to hospital.
“I am unable to conclude that Sarah’s death could have been prevented had she been appropriately observed overnight and in the morning on 19 November 2023,” he said in his findings on Wednesday.
“Even if hourly observations had been performed, Sarah would still have had an opportunity to take her life in the intervening periods.”
He noted Ms Skillington would not have been able to take her own life if the design of her room was different, an issue the hospital had since addressed.
A nurse who worked on the morning the 33-year-old was found dead concluded crumpled bed clothes might have been mistaken for Ms Skillington’s sleeping body.
The new mother had a difficult birth, experienced anxiety in the days after the delivery and suffered sleeplessness, the court heard.
She previously had disordered eating, health anxiety and reported “fleeting suicidal ideation”.
Ms Skillington said she was exhausted when admitted to hospital and the coroner noted the overnight nurse wanted to prioritise the mother’s sleep, which was in line with her treatment plan.
Her doctor did not determine she was suffering from postpartum psychosis when she was admitted, but Mr Ryan agreed with medical evidence she likely experienced the condition at her death.
The coroner described Ms Skillington, a well-regarded architect, as a remarkable woman and her death as a “tragedy which has devastated her family and friends”.
“Although the risk of self-harm cannot be completely eliminated for voluntary patients in mental health facilities, patients and families should be able to be confident that they will be appropriately supervised and cared for in a safe environment,” Mr Ryan said.
Recommendations to the hospital’s operator Ramsay Health included tests on its rooms, specific postpartum psychosis training for nursing staff and changes to admission forms.
In a statement, Ramsay Health Care offered condolences to Ms Skillington’s family and said the findings would be reviewed.
“We have offered to meet with her family, if and when they feel ready, should they wish to discuss any aspects of the findings and recommendations,” a spokesperson said.
Steps have been taken to implement all recommendations from a previous review to ensure safe and effective treatment was provided, they said.
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