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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
Had detailed, up to date and accessible plans been in place this would have
facilitated the continuity of care which was lacking as Louisa Ovington moved
between services. The panel fully understands the services’ difficulties in gaining
Louisa Ovington’s agreement to engage with them and notes on occasions her
outright resistance to any intervention. The presence of proper care plans
together with good inter-agency working would have enabled a more strategic
approach with realistic longer term objectives.
d) Maintaining a comprehensive history – There are copious records generated by
each of the mental health services with which Louisa Ovington had contact and
the panel has been in the privileged position of having access to what is believed
to be most of them, as well as to police and probation records. Despite the
quantity of information contained in them, there was no comprehensive (or even
summary), regularly updated history. It almost appears that each intervention
was the first episode in her care with little recognition of what went before. The
fact that she spent 18 months of her life, at a relatively young age, detained in
secure hospital facilities, did not appear to have registered, either at all or with
the significance that it merited.
Additionally there was little evidence of any attempt being made to consider
whether her psychological and behavioural problems were showing any sign of
improvement or deterioration.
e) Discussion with and assessment of families As has been previously noted in this
report little attempt appears to have been made to capture the views of either
Louisa Ovington’s partner or her family members. In particular, there are no
records that Mr Hilton was approached for his opinions or to have his needs
assessed as her ‘significant other’; this was most concerning given their volatile
history.
f) Discharge care planning – The clinical team at Kneesworth House will have
known from the first day of Louisa Ovington’s admission there that they would
have to make a recommendation to the court regarding disposal by 12 January
2000 when the Section 38 finally expired. However, the decision to recommend
a probation order with a condition of treatment was only made two days before
that court appearance. Until then, it appears that it was planned to recommend
that Louisa Ovington be detained under a hospital order. As a consequence of
this sudden and late change in plan, there was no time for a care planning
meeting to be held with the home team before discharge and there was no
discussion with probation, who concluded that they did not need to be involved.
The care package that was subsequently set up was not implemented and Louisa
Ovington became lost to services at this critical point.
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