Finding into death of Lynette Roberts

49y · Female·Motor vehicle accident related multi trauma including a severe head injury

Lynette Roberts, a 49-year-old with schizophrenia, died from motor vehicle collision while wandering aimlessly on a main street in Dunolly on 16 December 2010. She had blood alcohol level 0.16% and was wearing inappropriate heavy clothing on a hot day. She left a community mental health facility (Vahland Complex CCU) stating she was going to a supermarket, but actually went to relatives' homes on two previous days. On the day of death, nursing staff did not commence a thorough search for her absence until 5.10pm—over 5 hours after departure. The facility lacked formal leave policies and guidance for missing CCU patients. Risk assessments were not contemporaneously recorded. The decision to permit unescorted leave was based on clinical judgment and current mental state assessment, but insufficient account was taken of her demonstrated pattern of dishonesty about destination, known vulnerability, alcohol consumption, and cognitive dysfunction despite partial treatment response to clozapine.