Tracey Lynch

On the 13t of October 2015 I commenced an investigation into the death of Tracey Marie Lynch aged 39 years: The investigation concluded at the end of the Inquest which was concluded on the 19t May 2016. The conclusion of the Inquest was that Tracey Marie Lynch had committed suicide

Tracey Lynch, who was suffering from emotionally unstable personality disorder was admitted onto Stevenson Ward, secure psychiatric unit at The Harbour in Blackpool on the 17t March 2015 following an assessment and having attempted to hang herself from a tree: At a care programme approach meeting held on the 22nd June 2015 it was agreed that she should be discharged to a suitable rehabilitation unit: Following various assessments and the obtaining of funding was identified at Oswald House, in Oswaldtwistle It was agreed that she would be transferred on the 28* September 2015 it was recognised that the transition would be stressful and would lead to an even higher risk of suicide: That risk was not managed in that no final discharge meeting was held; no familiarisation visits were arranged for Miss Lynch and appropriate escorted transport was not arranged, En route to Oswald House a major incident occurred leading to Miss Lynch being Sectioned under the Mental Health Act and returned to The Harbour but placed on a different ward and with a different responsible clinician: There was a failure by The Harbour to carry out any assessment as to her then fitness to be discharged and a failure by Oswald House to carry out any assessment in relation to her suitability to Way Valley. day place and be admitted to Oswald House given the change in her presentation. She was transferred to Oswald House on the Sth October 2015 and at approximately 3pm on the gth October 2015 she hanged herself in the wardrobe of her room at Oswald House intending thereby to bring about her own demise:

In my opinion action should be taken to prevent future deaths I believe you have the power to take such action: the the the they being such the and