Inglis, Tracey Lee
Deceased
Tracey Lee Inglis
Demographics
37y, female
Date of death
2010-09-17
Finding date
2011-12-09
Cause of death
exsanguination from incised wounds to right wrist and elbow
AI-generated summary
Tracey Inglis, a 37-year-old woman with chronic pain from multiple orthopaedic injuries, hepatitis C, and a history of suicidal ideation, died by suicide while imprisoned. Critical clinical lessons include: the Initial Risk and Needs Assessment failed to identify her mental health and pain history due to inadequate information gathering and systemic failures; pain management was inadequate—she was transitioned from effective Panadeine Forte and tramadol in the community to suboptimal analgesia despite explicit requests and clinical evidence of severe pain; a six-day delay in verifying her prior medications compounded this; and Dr McDonald's clinical assessment that Ms Inglis had only neuropathic pain, not chronic pain, was incorrect and based on assumption rather than evidence. Sleep deprivation from untreated pain likely contributed to the suicide decision. Key preventable failures: incomplete IRNA using 'cut and paste' template answers; failure to access parole/probation reports; inadequate pain assessment and escalation; and lack of continuity in pharmacological management between community and custodial settings.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Contributing factors
- inadequate pain management
- failure to identify suicide risk during Initial Risk and Needs Assessment
- incomplete assessment of psychiatric history
- failure to access parole and probation service records
- delayed verification of community prescriptions
- sleep deprivation from untreated chronic pain
- clinical misassessment of pain aetiology and severity
- inadequate mental health consultation following reception
Coroner's recommendations
- QCS to review and limit the practice of cutting and pasting pre-prepared pro-forma answers in Initial Risk and Needs Assessment forms, with training that templates should only be used when no additional or variant information is forthcoming from prisoners
- QCS to extend the timeframe over which the IRNA process seeks information on suicidal or self-harm ideation beyond the current six-month window to capture historical mental health admissions
- Implement refresher training on the IRNA process for relevant QCS staff
- Update IRNA guidelines so staff are expected to inquire further into historical mental health issues
- Automatically refer all prisoners entering correctional centres for prescribed offences (including arson, murder, attempted murder, stalking) to Prison Mental Health Service
- Implement memorandum of understanding between QCS and Queensland Health regarding information sharing arrangements
- QCS to mandate that prisoners be explicitly asked whether they identify with any ethnic group and offered the option of having IRNA undertaken by a counsellor of their preferred gender to maximize likelihood of frank and truthful disclosure
- Queensland Health to urgently develop guidelines for Visiting Medical Officers in Offender Health Services regarding continuity of care for newly received prisoners, ensuring verification of existing prescriptions occurs in timely fashion
- Queensland Health to urgently develop comprehensive pain management guidelines for Offender Health Services to assist clinical decision-making regarding assessment and treatment of chronic pain
- QCS to require all prison operators to make information about the Health Quality and Complaints Commission readily available to prisoners and allow free telephone calls to the agency
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