Coroner demands action over '˜serious systems failure' at Blackpool's Harbour mental health facility
A mentally ill patient being transferred from The Harbour was sectioned after causing a serious crash on the M55 - but was released without being assessed and went on to kill herself, a coroner ruled.
Tracey Lynch managed to grab the steering wheel after a lone therapist was tasked with driving her across Lancashire, despite her mum warning she would try and jump from the vehicle, her inquest heard.
The 39-year-old was sectioned and taken back to Blackpool’s flagship mental health facility, but placed on a different ward and under the care of a different doctor, and later released without “any form of assessment whatsoever and with only a cursory glance at her previous records”, the hearing was told.
She was transferred to the Oswald House rehab unit in Oswaldtwistle, where she was found hanged days later.
Miss Lynch, from Chorley, died in October 2015 and her inquest held last May, but the full details of what happened have never before been reported.
Her death led to senior coroner Michael Singleton, now retired, to write to health bosses and demand action is taken to prevent a repeat.
Lancashire Care, which runs The Harbour, in Preston New Road, Marton, and is responsible for mental health care across the county, wrote back – and said a number of changes have now been made.
It said in a statement: “We are truly saddened by Tracey’s death and our thoughts are with her family. We have thoroughly reviewed the concerns raised in the Regulation 28 Notice and changes have been made to our policies and practice in order to improve quality and safety for patients in our care.”
Miss Lynch suffered from a personality disorder and was admitted onto the Stevenson Ward, a secure unit at The Harbour, on Friday, March 17, 2015, after trying to hang herself, Mr Singleton’s report said.
Three months later, it was decided she would be transferred to a rehab unit, and a place was found at Oswald House.
“It was agreed that she would be transferred on September 28 and it was recognised that the transition would be stressful and would lead to an even higher risk of suicide,” Mr Singleton wrote.
But no discharge meeting was held, and “appropriate escorted transport was not arranged”, he added.
Miss Lynch’s mum, Barbara, told the inquest 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”, Mr Singleton added.
He said: “Those concerns were not addressed such that on September 28 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 M55 motorway.
“Despite the fact that that risk had previously been identified, there was no attempt to seek to manage that in an appropriate way.”
Witnesses to the crash reported seeing Miss Lynch grappling with a man in the car before it veered into the central reservation, a spokeswoman for Lancashire Police said.
Mr Singleton added: “Having been detained by the police, and having then been assessed by mental health practitioners, Tracey Lynch was then detained under section three of the Mental Health Act 1983.
“She was taken from Preston police station to The Harbour. She was placed on a different ward and with a different responsible clinician, Dr Gangaraju.
“Without carrying out any form of assessment whatsoever, and with only a cursory glance at previous records, Dr Gangaraju immediately rescinded the section three and, without any consideration of the change in circumstance and the presentation of Miss Lynch, arranged for her immediate discharge to Oswald House.”
The inquest was also told how Miss Lynch’s previous pyschologist, Dr Zia, tried to contact Dr Gangaraju, but “her offer of assistance was refused.”
Mr Singleton added: “Having been detained for a second time there was no assessment and no care programme approach (CPA) meeting arranged. That appeared to be a serious systems failure.”
Lancashire Care’s response to Mr Singleton, seen by The Gazette, outlined the changes that have been made.
They included the “consistent application” of discharge policies, and “relevant and updated information regarding risk” being shared with all members of the team caring for patients.
“We are truly saddened by Tracy’s [sic] death and our thoughts are with her family,” director of nursing and quality Dee Roach wrote to Mr Singleton.
“We have taken time since the inquest, and thoroughly review the concerns raised in the regulation 28 notice, and to make changes to our policy and practice in order to improve quality and safety for patients in our care.”
The trust added in a statement: “The action taken as a result of her death and associated changes made continue to be monitored at a senior level in the organisation to ensure that we continue to learn and improve.
“We have provided the coroner with assurance that the appropriate action has been taken to address the concerns that he raised in order to improve the quality and safety of our services.”
A funeral service for Miss Lynch, who was described by her family as a “very dearly loved daughter,” a “loving sister,” and “much-loved auntie”, was held at Sacred Heart Roman Catholic Church in Chorley on Friday, October 23, 2015, followed by a cremation at Charnock Richard Crematorium.
Donations to mental health charity Mind were requested in lieu of flowers.
Doctor ‘deviated from legal duty’ in second case months beforehand
The doctor accused of rescinding Tracey Lynch’s section order without assessing her ‘deviated from his legal duty’ months earlier, a separate inquest was told last year.
Dr Chandrashekar Gangaraju signed off tragic Sally Hickling’s paperwork without seeing her himself, because two other doctors were not yet qualified to complete certain tasks, Blackpool town hall heard last year.
Resort coroner Alan Wilson asked him: “You acknowledge you had not seen or had any dealings with Sally Hickling?”, and “When you were approached and were asked about the consent to treatment form, you were aware it was your duty to have spoken to Sally?”
Dr Gangaraju answered “yes” to both questions but said he trusted the doctors’ judgments, The Gazette reported last year.
Miss Hickling, 20, from east Lancashire, died after being found with a ligature around her neck, with her inquest ruling that experts at The Harbour “inappropriately” reduced her observation levels and left her alone for 21 minutes – more than double what they should have.
Her death, on July 30, 2015, came just months before Miss Lynch’s on October 9.
Lancashire Care later apologised to Miss Hickling’s family, saying in a statement: “An independent investigation took place immediately after her death and highlighted the need for some key quality improvements that have since been made.”
Dr Gangaraju, who qualified from the University of Mysore in India in 1996, is still registered to practise, the General Medical Council (GMC) confirmed, and is not subject to any conditions or restrictions.
Lancashire Care’s director of nursing and quality Dee Roach told coroner Michael Singleton, who held the inquest into Miss Lynch’s death: “The concerns in respect of Dr Gangaraju have been referred to the medical director of the trust, Professor Max Marshall, who is progressing those concerns through the medical professional standards process.
“I am also aware that Dr Gangaraju has self-referred to the General Medical Council following the inquest.”
Lancashire Care confirmed he is still employed by the trust.