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

More documents

Recommendations

Info

CHAPTER 6 – RISK ASSESSMENT AND MANAGEMENT 116 • 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.
CHAPTER 6 – RISK ASSESSMENT AND MANAGEMENT It is apparent that formal risk assessment was undertaken periodically by several agencies but the outcomes are not as informative as one would expect and regrettably there is little evidence that any consistent action was implemented as a result. There were clearly opportunities for addressing some of the concerns and these were missed. A referral to MAPPA would have enabled a rigorous risk assessment to be completed based on the information which each agency held. But even without the benefit of the MAPPA approach, the agencies failed to work together consistently and effectively to manage Louisa Ovington’s risk. The conclusions and recommendations in this report deal with this aspect 117
Page 1:
REPORT TO THE NORTH EAST STRATEGIC
Page 5 and 6:
Contents CONTENTS Page Preamble 6 I
Page 7 and 8:
Introduction and terms of reference
Page 9 and 10:
The panel met on 14 occasions, tota
Page 11 and 12:
CHAPTER 1 - NARRATIVE OF KEY DATES
Page 13 and 14:
This opinion was referred to by man
Page 15 and 16:
Page 17 and 18:
20 May 1998 to 12 January 1999 CHAP
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
60. As was common in 1998, there we
Page 25 and 26:
Page 27 and 28:
women. Registrar 1 prepared a very
Page 29 and 30:
77. One of the major components of
Page 31 and 32:
visit to see him. A little later, o
Page 33 and 34:
93. The final report from the psych
Page 35 and 36:
Page 37 and 38:
surprised and told the panel that h
Page 39 and 40:
• Consultant 9,in his evidence to
Page 41 and 42:
Page 43 and 44:
129. Although Louisa Ovington conti
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
there was “some latitude” in th
Page 53 and 54:
61 14th offence 62 15th offence 63
Page 55 and 56:
176. Social Service staff did respo
Page 57 and 58:
Page 59 and 60:
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 and 110: COMMENT The probation officer estab
Page 111 and 112: CHAPTER 5 - INVOLVEMENT WITH POLICE
Page 113 and 114: COMMENT CHAPTER 5 - INVOLVEMENT WIT
Page 115: 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
Page 161 and 162: Bibliography 1. Effective Care Coor
Page 164: INTRODUCTION 28 North East Strategi
show all

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

Create successful ePaper yourself

Delete template?

Save as template?