“being as follows: - 1”

The coroner’s concerns

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being as follows: - 1. Despite the fact that there had been a clear change in the presentation of Tracey Lynch following the CPA Meeting on the 22"? June and despite the fact that arrangements for discharge were not in place until the 28" September 2015 no final discharge meeting was held, that is despite the fact that the responsible cincer a the care co-ordinator I WN and the deputy manager from Oswald House J had all indicated that they wished for there to be a final discharge meeting. There seemed to be no system in place to ensure that such a meeting would take place and in order to ensure that appropriate management would take place of the discharge to a rehabilitation unit. 2. The evidence was that familiarisation visits would have been of considerable assistance to Miss Lynch in the lead up to her discharge to Oswald House. Despite that being accepted there appeared to be no system in place to ensure that such familiarisation visits would take place. 3. The evidence was tha the mother of Tracey Lynch, had alerted the care co-ordinator and the responsible clinician with her concerns that her daughter’s state of mind was such that unless she was properly and appropriately escorted in the transport from The Harbour to Oswald House that she would attempt to jump from the motor vehicle. Those concerns were not addressed such that on the 28" September when only escorted by the occupational therapist who was driving the vehicle Miss Lynch was able to grab the steering wheel and cause a serious accident on the MSS motorway. Despite the fact that that risk had previously been identified there was no attempt to seek to manage that in an appropriate way. 4. Having been detained by the Police and having then been assessed by Mental Health Practitioners Tracey Lynch was then detained under Section 3 of the Mental Health Act 1983. She was taken from Preston Police Station to The Harbour at Blackpool. She was placed on a different ward and with a different responsible — Without carrying out any form of assessment whatsoever and with only a cursory glance at previous records i immediately rescinded the Section 3 and without any consideration of the change in circumstance and presentation of Miss Lynch arranged for her immediate discharge to Oswald House. The evidence was that the Consultant Psychologist, who had previously been dealing with Miss Lynch attempted to contact but her offer of assistance was refused. Having been detained for a second time there was no assessment and no care programme approach meeting arranged. That appeared to be a serious systems failure.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2016-0211

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0