Tracey Lynch

1. 1. lack of final discharge meeting

   “Despite the fact that there had been a clear change in the presentation of [the deceased] following the CPA Meeting on the 22TM June and despite the fact that arrangements for discharge were not in place until the 28% September 2015 no final discharge meeting was held”

2. 2. lack of familiarisation visits

   “The evidence was that familiarisation visits would have been of considerable assistance to Miss [name redacted] in the lead up to her discharge to Oswald House”

3. 3. inadequate escorted transport

   “the mother of [the deceased], 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.”

4. 4. improper discharge after Section 3

   “Having been detained by the Police and having then been assessed by Mental Health Practitioners [the deceased] was then detained under Section 3 of the Mental Health Act 1983.”

No published response was found on judiciary.uk.