Finding into death of Kim Rebecca Lynch

41y · Female·neck compression

Kim Lynch, 41, died from neck compression between 12-14 February 2016. She was in a relationship with LM, who had paranoid schizophrenia, substance abuse issues, and a history of violence. Following a family violence incident on 17 January 2016 where LM assaulted her, Lynch obtained an intervention order. However, critical information about this violence was not communicated between Monash Health's community and inpatient mental health teams. On 5 February, LM was granted three-hour supervised leave despite high-risk status; he absconded and met with Lynch. The AWOL procedure had gaps: the Psychiatric Triage Service wasn't notified, nominated contacts weren't contacted within 30 minutes, and the missing person investigation lacked CIU notification and adequate follow-up despite high-risk categorisation. Communication failures between services, incomplete information sharing during leave approvals, and inadequate missing person investigation protocols all contributed to preventable gaps in protection.