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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
Chapter 9 – Conclusions and recommendations
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As will be clear from the narrative of significant events in chapter 1 of this report
Louisa Ovington’s path through her ten years of involvement with the services was
far from straightforward; it was crowded with obstacles and was both multi layered
and multi stranded. The panel has attempted to produce from the 6500 or so pages
of information available to it, (enhanced by the oral evidence given) a reasonably
coherent and readable, if lengthy, report. Because of the complexity of Louisa
Ovington’s needs and the many agencies involved there has been some inevitable
repetition in the panel’s analysis of the significant aspects of Louisa Ovington’s
treatment and care set out earlier in this report.
As the panel’s work progressed it became clear however, that there were a number
of issues which had particular significance in the context of Louisa Ovington’s journey
through the mental health services and which impacted adversely on the quality of the
health care and treatment afforded to her.
These included:
• The circumstances leading to the decision to admit Louisa Ovington to
Kneesworth House, the process which resulted in her discharge and her aftercare
arrangements.
• The unsatisfactory way in which, with some exceptions, the CPA was applied,
throughout the time when she was supposed to be subject both to CPA and
Section 117 of the Mental Health Act.
• The effect on patient care of major reorganisations and staffing shortages.
• The failure to give sufficient weight to the impact of drug and alcohol abuse
upon Louisa Ovington’s general mental health.
• The failure to engage Louisa Ovington with psychological treatments or to refer
her to forensic services in the community.
• The failure to invoke public protection arrangements (MAPPA).
• Inadequate collaboration between services, including the failure to share
information between the agencies.
Overall, the panel concluded that, if the agencies involved with Louisa Ovington had
worked together more effectively, it is possible that Mr Hilton’s death would not have
occurred.