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

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CHAPTER 7 – PROVISION OF MENTAL HEALTH SERVICES Chapter 7 – Provision of mental health services 118 Introduction Key features of Louisa Ovington’s passage through mental health services were the challenges presented by her regular changes of address, including times where she was of ‘no fixed abode’; her own complex interconnected mixture of needs arising from mental disorders, sometimes as a consequence of substance abuse; and behavioural problems leading to her extensive involvement with the criminal justice system. Two other factors were also present which impacted on her care, the modernisation of mental health services and the service reconfigurations linked to organisational mergers. Louisa Ovington’s copious clinical records describe a journey from Edinburgh to Easington and its surrounding areas in the north east and contain detailed information on her experiences in both hospital inpatient and community environments. Her journey also extended to Hertfordshire where she spent several months in a private psychiatric hospital. The following sections attempt to highlight the numerous agencies and teams with which she came into contact, the policies in place at the relevant periods and the positive or negative effects of them on Louisa Ovington’s care. Service configuration There were numerous organisations which were responsible at different times for providing care to Louisa Ovington and the key ones are listed below as they were then known: • County Durham & Darlington NHS Trust • Durham County & Darlington Priorities Services NHS Trust • Tees and North East Yorkshire NHS Trust • Newcastle City Health NHS Trust • Hartlepool & East Durham NHS Trust • Hartlepool Community Care NHS Trust • South Tees Community & Mental Health NHS Trust • North Tees & Hartlepool NHS Trust
• South West Durham Mental Health NHS Trust • Edinburgh Healthcare NHS Trust • Easington Primary Care NHS Trust • Tees Health Authority • Partnerships in Care • County Durham Social Services • County Durham Probation Services • Teesside Probation Service CHAPTER 7 – PROVISION OF MENTAL HEALTH SERVICES Louisa Ovington was treated at the following hospitals: • Hartlepool General Hospital, Hartlepool • The Duggan Keen Unit at Winterton Hospital, Sedgefield • The Royal Edinburgh Hospital • The Tony White Unit at the County Hospital Durham • Cuthbert Ward (forensic unit) St Nicholas Hospital, Newcastle, • Clopton Ward, Kneesworth House, Hertfordshire • Darlington Memorial Hospital In addition, between 1995 and 2006 Louisa Ovington was supported by the following mainstream community teams: 1995 - 2000 Hartlepool Community Mental Health Team 2001 - 2003 Newton Aycliffe Community Mental Health Team 2000 - 2001 Community Addictions Service 2001 - 2002 Hartlepool Mental Health Day Services 2003 - 2004 Easington Substance Misuse Initiative 2003 - 2006 Easington South Community Mental Health Team 2004 - 2005 Crisis Resolution Team 2004 - Brief involvement Hartlepool Social Services 119
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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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78 21st offence 204. However Louisa
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hours. They did not have access to
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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 and 116: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 117: CHAPTER 6 - RISK ASSESSMENT AND MAN
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
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Lousia Ovington independent investigation report ... - NHS North East

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