A violent patient killed his Hallam partner after being granted leave from Dandenong Hospital psychiatric unit in the absence of “critical information”, according to a State Coroner’s finding on 7 September.
Police found Kim Rebecca Lynch, 41, strangled dead in a closet in a house in February 2016.
On 30 January 2016, her killer LM was admitted as an involuntary psychiatric patient at Dandenong Hospital after telling paramedics he’d injected himself with poison.
He said he would murder everyone around him if it was not removed.
The man had an “extensive history” of mental illness including aggression and violence. He had file alerts of a “high risk” of absconding, aggression and substance use, State Coroner John Cain noted.
Six days after admission, LM was granted three hours leave to visit his grandmother and went AWOL.
At the time, he had been served with a family violence safety notice due to recently chasing and repeatedly punching Ms Lynch on the street.
An intervention order was also granted, which was left at LM’s house in his absence.
Monash Health doctors stated they were unaware at the time of LM’s violence to Ms Lynch or of the intervention order.
They were also unaware of a Monash Health clinician’s notes that LM’s house was in disarray with bags of meth found as well as Ms Lynch reporting being assaulted by LM.
“It is fair to say that some of the information on which (a Monash Health doctor) relied when granting LM leave on 5 February 2016 was misleading and/or unreliable,” Judge Cain stated.
“It is also fair to say that information critical to the decision to grant leave to LM was unavailable.”
Judge Cain found that the doctor’s decision was reasonable on the evidence available to her.
After being granted leave, LM refused to return to hospital.
Victoria Police was notified and a missing person investigation was launched. However, the missing person report failed to identify LM’s risk of inflicting family violence, Judge Cain noted.
There was also no evidence that a police unit tried to find LM at home.
Monash Health failed to notify LM’s community mental health team or to ask the grandmother and stepfather to help locate him – which was a “missed opportunity to potentially … return him to hospital before causing harm to Ms Lynch”.
“The medical record did not indicate any attempts to contact LM while he was AWOL and it appeared that he was discharged 28 hours after he was reported AWOL.”
In the meantime, Ms Lynch reported to an associate that she’d been bashed at LM’s house on 11 February.
The last time Ms Lynch was seen alive was while returning to the house on 12 February to collect personal items and end the relationship. She said she would report LM for breaching the intervention order.
On 14 February, LM rang triple-0 to ask to be returned to Dandenong Hospital. On 20 February, he rang his stepfather from hospital to say there was a body at his home – which was reported to police.
Judge Cain stated Ms Lynch, a mother of three with a complex mental health history, had been subjected to violence from partners in the past.
After the earlier family violence, police appropriately assessed her family violence risk, and took her to hospital for mental health assessment, Judge Cain stated.
Police referred Ms Lynch for safe housing at WAYSS, which undertook “inadequate” family violence risk assessment and safety planning.
“However, it is noted that the only action on the safety plan was ‘call 000’ which appears inadequate given the risk assessment guidelines applicable at the time.”
Ms Lynch declined an offer for crisis accommodation, saying she felt safe at LM’s house.
Judge Cain noted significant changes had been implemented in the family violence sector since a recent Royal Commission. A mental health Royal Commission was expected to lead to further improvements.
“The investigation into Ms Lynch’s death highlights the importance of robust systems to ensure the timely communication of accurate information critical to decision makers and their decisions.”
