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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
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than he did. For those six months, Consultant 2 appears to have been the
nominated care coordinator. It was Staff Grade Psychiatrist 1 who was following
Louisa Ovington up in outpatients and only he who (in theory) was seeing her
regularly. Social Worker 7 worked well with the other agencies involved with
Louisa Ovington, attempting to arrange case conferences and MAPPA meetings.
CPN 2 was only involved with Louisa Ovington for a couple of months before the
homicide occurred.
It is quite clear in the guidance produced by the Department of Health in 1999
that the appointment of a care co-ordinator was a key component in ensuring
the success of Effective Care Co-ordination. It is reasonably clear from the
records who had this responsibility at any given time apart from one spell in
2004. What is less clear however is how well this responsibility was discharged.
There were some attempts made at pulling together interested parties to CPA
meetings although these were infrequent and poorly attended. (There was
however evidence of good practice in calling CPA meetings at moments of
crisis or acute concern, although the nature of these last minute meetings meant
that, often, essential professionals could not attend) .With the exception of
Social Worker 4 and Social Worker 7, the panel’s view is that the Louisa
Ovington’s care was poorly coordinated. There was little or no overview and the
impression was one of ‘fire-fighting’ when necessary and dealing with issues
as they arose. There was no sense of purpose or direction with resolving her
psychological problems and very little progress with her social issues. The
guidance outlined by the Department of Health in 1999, provided a clear vision
of the role of the care co-ordinator and with it the opportunities to plan care and
commit resources. There is little evidence of this occurring.
b) CPA levels/Section 117 Mental Health Act – It was unclear at times what level of
CPA was in place and it appears from the records that it may have varied
between ‘standard’ and ‘enhanced’. The panel was surprised that, given the
history of violence, arrests, convictions, behavioural disturbances and abuse of
drugs and alcohol which required almost a constant multi-agency involvement,
Louisa Ovington was not maintained on enhanced CPA and subject to regular
CPA and Section 117 reviews. In the case of Section 117 this was a statutory
obligation deriving from her very first stay in hospital and in addition following
her detention under Section 37. It should never have been overlooked.
c) Care planning forming the basis of treatment – Key components in ensuring the
successful application of the CPA are the systematic recording, reviewing
(incorporating the views of all relevant parties) and auditing of care plans. The
panel could find little documentary evidence that this consistently occurred. It is
clear however that on the occasions when care plans were completed,
compliance with CPA objectives was patchy and the policing of this was minimal.