Finding into death of Kim Rebecca Lynch

Contributing factors

• failure to communicate critical information about family violence between community and inpatient mental health teams
• inadequate handover of information regarding recent violence and intervention order prior to leave approval
• decision to grant supervised leave despite high-risk patient status without complete risk assessment
• absence without leave procedure not followed: Psychiatric Triage Service not notified, nominated contacts not contacted within 30 minutes
• inadequate missing person investigation: failure to notify Criminal Investigation Unit despite high-risk categorisation
• lack of active search or investigation at patient's home address between 5-14 February 2016
• poor documentation and accessibility of critical information across different mental health service teams
• inadequate supervision of leave decision by substitute psychiatrist

Coroner's recommendations

1. Establish systems to ensure timely verbal handover of critical information between clinicians not operating from a shared setting, particularly between community and inpatient mental health teams
2. Consider establishing a register of patient leave escorts and their contact details maintained in a central location at inpatient units to facilitate communication during AWOL situations
3. Ensure psychiatrists granting leave on behalf of a consultant colleague review the medical record and directly assess the patient when first-hand information is not available
4. Implement processes to reconcile information provided by reporting parties (such as mental health services) with how that information appears in police systems (LEAP) for missing person investigations
5. Ensure Criminal Investigation Unit is promptly notified of all high-risk missing person reports as per Victoria Police Manual procedures
6. Implement regular documented reviews and 'checks' of missing person investigations at prescribed intervals (days 3 and 7) as per Victoria Police procedures
7. Strengthen supervision of missing person investigations to ensure adequate progress, necessary inquiries are made, and inadequacies are identified
8. Provide training to police members on recognition and recording of critical information relevant to missing person investigations, including family violence context
9. Continue implementation of reforms recommended by the Royal Commission into Family Violence and Royal Commission into Victoria's Mental Health System
10. Establish cross-organisational information sharing mechanisms between mental health services and Victoria Police for patients subject to compulsory treatment orders who are also subject to family violence intervention orders