Lousia Ovington independent investigation report ... - NHS North East

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110 CHAPTER 5 – INVOLVEMENT WITH POLICE AND PROBATION CRO dated 10 September 2004 On 10 September 2004 Louisa Ovington was made subject to a two year CRO managed by County Durham Probation Service. Difficulties arose when Louisa Ovington moved, shortly after the imposition of the CRO, from the County Durham probation area into temporary accommodation in the Hartlepool area. At first, Hartlepool was asked to ‘caretake’ the case and then the order was formally transferred to Hartlepool on 5 November 2004. On 27 July 2005, as Louisa Ovington had moved back into the County Durham probation area, the order was transferred again. The situation was further confused by the fact that Louisa Ovington attended from time to time at both offices regardless of which service had responsibility for the order. Additionally Louisa Ovington spent some time on remand. Notes on the file indicate probation’s own concerns about the management of the order. The records in relation to this CRO indicate that various officers were expending considerable energy in dealing with Louisa Ovington’s housing problems. As part of the CRO, Louisa Ovington was required to undertake a ‘citizenship’ programme with modules in anger management and alcohol. There are no details in the probation file about the content of the modules, nor whether they were completed. There is evidence in the records of ongoing contact between Louisa Ovington’s care coordinator and the probation officers who were dealing with Louisa Ovington at any one time. In relation to Louisa Ovington’s risk to the public, the care coordinator, over the period of a week or so in October 2004, was expressing real concern to Probation and several times raised the matter of whether a “public protection meeting” should be held. Probation’s view was that Louisa Ovington did not present sufficient risk, despite a report that Louisa Ovington had made threats to kill Mr Hilton. COMMENT The management of this CRO seems to have been bedevilled by Louisa Ovington’s chaotic lifestyle, making her supervision very difficult indeed. Probation Manager 1 told the panel that probation should have acted to clarify “who was responsible for what” as Louisa Ovington would not have been alone in being a ‘very chaotic offender’. It seemed to her that Louisa Ovington was ‘calling the shots’ and manipulating the system. Current rules prevent ‘caretaking ’arrangements and stipulate that there has to be a clearly identified person to manage the order.
CHAPTER 5 – INVOLVEMENT WITH POLICE AND PROBATION One of the problems was that there were two different systems of recording in place in Teesside (Hartlepool) and Durham; this meant that information (for example, in relation to serious domestic incidents) might have been, in Probation Manager 1’s words “lost”. This itself would have militated against a proper understanding of risk. The panel noted that the care coordinator expressed her concerns about risk to probation more than once and was told that Louisa Ovington either did not fit the criteria for a ‘public protection meeting’ or that in probation’s views there were “no current risk of harm issues”, despite the reports that Louisa Ovington had made threats to kill Mr Hilton. Probation Manager 1 expressed surprise to the panel about probation’s response; she suggested that the care coordinator could have made a referral to MAPPA herself; however she conceded that if the care coordinator had specifically raised the issue of MAPPA with probation it would have been reasonable for her to accept their view. The panel however noted that probation, with the police (and later the prison service) constituted the MAPPA ‘Responsible Authority’ (and that the County Durham Probation Service acknowledged the strengths of the MAPPA system in their third annual MAPPA report in 2003/4, at a time when Louisa Ovington was behaving as though she was out of control and was causing great concern to the health and social care agencies). The terminology in relation to public protection at this time was confused; the terms public protection meeting and risk meeting and MAPPA seem to have been used loosely and interchangeably. (Probation Manager 1 also told the panel that at the time there was confusion about the various MAPPA levels; the terminology is now clearer.) What was clear was that the care coordinator had serious concerns, which had been expressed to the CMHT, Staff Grade Psychiatrist 1, the CRT and probation and that she looked to probation as the persons who had the necessary expertise to make a decision on whether the level of risk was serious enough to warrant a multi-agency response. When they decided it was not, she presumably accepted that view. (It is also of note that the probation officer who prepared the PSR which preceded the CRO had assessed the risk as high and the OASys assessment had indicated that a referral to MAPPA was called for). The panel’s view is that according to the criteria at the time, as set out in the guidance for probation 90 Louisa Ovington would not have fitted MAPPA Categories 1 or 2. However, given the commission of several offences showing that she was capable of causing serious harm to the public, given her general forensic history, her alcohol and drug misuse, her mental health problems, her frequent threats to kill, her frequent use or threat of the use of knives, her chaotic and unstable lifestyle and her out of control behaviour particularly in 2004, she would have been likely to fulfill the criteria for Category 3. She would probably have been managed at level two, which would have enabled all the agencies dealing with her ( health, social care, drug and alcohol teams, housing, police and probation), to share their knowledge formally. 90 MAPPA Guidance Probation 111
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REPORT TO THE NORTH EAST STRATEGIC
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Contents CONTENTS Page Preamble 6 I
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Introduction and terms of reference
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The panel met on 14 occasions, tota
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CHAPTER 1 - NARRATIVE OF KEY DATES
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This opinion was referred to by man
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20 May 1998 to 12 January 1999 CHAP
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60. As was common in 1998, there we
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women. Registrar 1 prepared a very
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77. One of the major components of
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visit to see him. A little later, o
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93. The final report from the psych
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surprised and told the panel that h
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• Consultant 9,in his evidence to
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129. Although Louisa Ovington conti
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there was “some latitude” in th
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61 14th offence 62 15th offence 63
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176. Social Service staff did respo
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Page 59 and 60: CHAPTER 1 - NARRATIVE OF KEY DATES
Page 61 and 62: 78 21st offence 204. However Louisa
Page 63 and 64: hours. They did not have access to
Page 65 and 66: 210. CPN 2 also completed a risk as
Page 67 and 68: Chapter 2 - Evaluation of the healt
Page 69 and 70: CHAPTER 2 - EVALUATION OF THE HEALT
Page 71 and 72: During Louisa Ovington’s first ad
Page 73 and 74: Kneesworth House Louisa Ovington co
Page 75 and 76: The conclusion drawn by the psychol
Page 77 and 78: On 10 July 2001 Louisa Ovington att
Page 79 and 80: take part in several sessions of a
Page 81 and 82: COMMENT CHAPTER 2 - EVALUATION OF T
Page 83 and 84: CHAPTER 2 - EVALUATION OF THE HEALT
Page 85 and 86: CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 87 and 88: CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 89 and 90: CHAPTER 4 - THE CARE PROGRAMME APPR
Page 97 and 98: The essence of CPA is to ensure car
Page 99 and 100: Chapter 5 - Involvement with police
Page 101 and 102: 89 ibid The guidance states that th
Page 103 and 104: DS1 told the panel bluntly that, in
Page 105 and 106: and social care agencies. The panel
Page 107 and 108: CRO with a condition of psychiatric
Page 109: COMMENT The probation officer estab
Page 113 and 114: COMMENT CHAPTER 5 - INVOLVEMENT WIT
Page 115 and 116: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 117 and 118: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 119 and 120: • South West Durham Mental Health
Page 121 and 122: CHAPTER 7 - PROVISION OF MENTAL HEA
Page 123 and 124: The policy changes were driven by t
Page 125 and 126: • Past psychiatric history; • S
Page 127 and 128: CHAPTER 8 - USE OF THE MENTAL HEALT
Page 133 and 134: Given the multiplicity of agencies
Page 135 and 136: CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 139 and 140: Some of the risk assessments from a
Page 143 and 144: • Recommendation 16. Trusts shoul
Page 145 and 146: f) Use of “talking therapies” C
Page 147 and 148: professional who had seen her withi
Page 149 and 150: i) Joint working CHAPTER 9 - CONCLU
Page 151 and 152: their procedures for formal contact
Page 155 and 156: LIST OF RECOMMENDATIONS • Recomme
Page 157 and 158: LIST OF RECOMMENDATIONS • Recomme
Page 159 and 160: LIST OF RECOMMENDATIONS • The pol
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Bibliography 1. Effective Care Coor
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INTRODUCTION 28 North East Strategi
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Lousia Ovington independent investigation report ... - NHS North East

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