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

More documents

Recommendations

Info

CHAPTER 7 – PROVISION OF MENTAL HEALTH SERVICES 126 The panel was informed by Team Manager 2 of the efforts made to encourage joint working, but for a number of reasons this did not seem work well in relation to Louisa Ovington. She was an ideal candidate for comprehensive joint working, particularly given that her presentation was complex, that she was involved with a number of agencies and that she was capable of dangerous behaviour. She merited being continuously on enhanced CPA and her history should have been properly considered through the risk assessment process. The policies clearly identify the roles of the teams and their aims and objectives and at first sight constitute a commendably thorough approach when read together. In practice, however, little change took place in how the services worked together in dealing with the issues and concerns which were emerging with increasing regularity in the lives of Louisa Ovington and Mr Hilton.
CHAPTER 8 – USE OF THE MENTAL HEALTH ACT AND COMPLIANCE WITH THE CODE OF PRACTICE Chapter 8 – Use of the Mental Health Act and compliance with the Code of Practice At all relevant times in the period during which Louisa Ovington was receiving mental health services, the legislation regulating the detention of mentally disordered people was the Mental Health Act 1983, prior to its amendments in 2007. The Act was supported by the Code of Practice (Government guidance) in force from 1 April 1999. The preamble to the Code states: “The Act does not impose a legal duty to comply with the Code but as it is a statutory document, failure to follow it could be referred to in legal proceedings.” It is widely accepted as a baseline of good practice, from which deviation requires justification. The Act sets out the strict criteria under which persons suffering from various types of mental disorder can be detained and the safeguards in place for such detention. Distinction is made between those persons detained after, or during, involvement with the criminal justice system and those who are detained without such involvement. The following is (as accurately as can be established) a list of the occasions when Louisa Ovington was detained in a psychiatric hospital under the Act: • On 23 December 1995 Louisa Ovington was admitted to Hartlepool General Hospital informally (i.e. without compulsory detention). • From 24 January 1996 to13 March 1996 she was detained, while in hospital, under Section 3 of the Act, which provides for detention for treatment for up to six months, if certain conditions are met. COMMENT There is nothing to indicate that this was an inappropriate detention. Louisa Ovington was suffering from psychotic episodes and at one point her behaviour became so hard to contain that she was transferred to a psychiatric intensive care unit where she could be better managed. She was only detained for two months, although she was in hospital for longer. There was no evidence that she had recourse to any of the safeguards under the Act - for example Mental Health Review Tribunals 91 or Hospital Managers’ 92 review powers - nor that she wished to do so but was prevented from doing. This detention however had highly significant consequences, for a patient detained under Section 3 (and some other sections) of the Act acquires, through the operation of Section 117, a right to free after care services. Section 117 of the Act imposes a duty on local authorities and health authorities to provide after care services once the patient is no longer detained. The right and the corresponding duty, continue indefinitely, unless the authorities deem it no longer necessary (and they have not done so in Louisa Ovington’s case). Therefore for all the periods of time 91 A review by a judicial body of whether the criteria for detention remain satisfied. 92 A review by specially appointed Mental Health Act managers as to whether the detention should remain in place. 127
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 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: • Past psychiatric history; • S
Page 129 and 130: CHAPTER 8 - USE OF THE MENTAL HEALT
Page 131 and 132: 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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?