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Coroner David Ryan found that Skillington’s death could have been prevented if hospital staff had followed their own protocol, which required hourly overnight checks. Instead, a series of serious oversights allowed her to go unattended and ultimately die in a hospital bathroom. It was among several damning findings following the five-day inquest into her death. “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.” 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.
