Inglis, Tracey Lee

37y · Female·exsanguination from incised wounds to right wrist and elbow

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.