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

Given the multiplicity of agencies involved with Louisa Ovington at any one time, the
panel found it hard to attribute clear responsibility to specific agencies or individuals:
the failures seemed to be more rooted in systemic inadequacies than individual
shortcomings; however, there were instances of practice that fell short of acceptable
standards of care.
Louisa Ovington’s presentation over a period of years reflects, the panel suspects, the
reality that faces many mental health agencies. Her difficulties, after she suffered a
highly traumatic event as a young child, showed in ways that were neither particularly
dramatic nor unique. They were chronic and deep seated and resulted in years of
disruptive behaviour, culminating in an event which tragically ended her victim’s
life, altered his family’s life forever and effectively ruined her own. Her problems
were not susceptible to a quick, obvious solution. The following conclusions and
recommendations seek to deal with specific areas of practice which, were the
recommendations to be acted on, would result in better, more coherent and more
robust care for patients such as Louisa Ovington.
The panel also acknowledges that because of the number of professionals involved in
her care, the following conclusions and recommendations have a degree of overlap.
i. CPA/Care coordination
There is no reason why staff should not now be familiar with the requirements of the
CPA. It is clear from the actions/omissions of staff involved with Louisa Ovington that
most did not for whatever reason follow the guidance issued in ‘Effective Care Coordination’
and appeared at best to apply the requirements in a ‘mechanistic’ way.
The opportunities afforded through the practical application of the CPA were not
maximised in this case.
Particular issues of note were:
CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
a) Role of care co-ordinator – During the five years following her discharge from
Kneesworth House, Louisa Ovington had at least six different care coordinators
and several consultants were at least nominally involved with her care, though
she mainly saw Staff Grade Psychiatrist 1. The quality of the input from the
different professionals varied. Social Worker 2, despite her pivotal role as Louisa
Ovington’s first care coordinator post discharge after 18 months in hospital,
never saw Louisa Ovington. Social Worker 4 had extensive useful contact with
her. Social Worker 5 failed to ensure that Louisa Ovington had proper follow-up
when she left her post. The panel was concerned that Louisa Ovington was
effectively left without a care coordinator for six months and considers that Team
Manager 3 should have stepped in and allocated a worker to her much sooner
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