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

CHAPTER 6 – RISK ASSESSMENT AND MANAGEMENT
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• 1999 Letter from Consultant 10, Rampton Hospital (“Louisa Ovington is complex
and quite profoundly disturbed – needs period of treatment in controlled
setting...adequate support otherwise the consequences could be serious or
grave”).
• 1999 Letter from Specialist Registrar 1 to court (“Louisa Ovington has severe
personality disorder with subsequent dangerous behaviour”).
• 2000 Letters from Kneesworth House post discharge - (“no sign of mental
illness, no bad behaviour”).
• 2001 Risk assessment at Darlington Memorial Hospital signed by Consultant 15
(“no risk of violence or assault against others”).
• 2002 Psychotherapist 1 report notes “Louisa Ovington would not be at risk. CPA
minimum level”.
• 2004 Risk assessment in A&E by CRT (“thinks of suicide daily”).
• 2004 Further CRT risk assessment (“risk minimal if abstains from alcohol”) and a
later assessment which determined she had no intention to kill her partner.
• 2004 Assessed in A&E by psychiatrist (“no risk to self”).
• 2004 Assessed at case conference where the care coordinator Social Worker 7
stressed the importance of keeping in touch with her and noted that
consideration should be given to a MAPPA meeting given her potential risk to
self and others.
• 2005 Risk assessment undertaken by new care coordinator CPN 2 regraded to
enhanced CPA.
• In addition there were various risk assessments conducted by probation under
their Offender Assessment System (OASys), which show different levels of
assessed risk, or on occasion an apparent ‘mismatch’ between the assessed risk
and the action taken or recommended.
COMMENT
The examples referred to above reflect Louisa Ovington’s unstable lifestyle with
periods of relatively low risk behaviour followed by escalation (generally coinciding
with increased substance or alcohol use) particularly during 2004 and 2005 when
her care coordinator and the CRT manager, were sufficiently concerned to consider
making a request to convene a public protection meeting.