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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
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It was of concern to the panel that although Consultant 9 offered to accept
continuing responsibility for Louisa Ovington and offered the forensic services at
Newcastle as a point of contact for Kneesworth House, the staff at Kneesworth
House did not keep him informed about Louisa Ovington’s progress. Neither he
nor the forensic team were involved in any discharge planning. Furthermore,
there was no evidence of any correspondence from Kneesworth House with the
funding authority.
There was a Locality care coordinator at the time (Social Worker 2) who did have
dealings with Kneesworth House. However she did not seem to regard it as
necessary to keep Consultant 9 informed.
g) Transfers – Transfers of care coordination were variably managed. The panel was
told by the care coordinators whom they interviewed that they were only given
limited information about Louisa Ovington when they began their work with her.
From review of the notes, it is apparent that only one care coordinator actually
introduced the new care coordinator to Louisa Ovington when they handed over
her care. Social Worker 5 concluded that Louisa Ovington did not require a
CMHT worker; she discharged Louisa Ovington from the team and it was only a
month later that she wrote to Consultant 2 to inform him that he was to be the
care coordinator. There is no evidence that he ever met her. Patients often have
difficulty in coping with changes in workers and it was notable to the panel that
Louisa Ovington’s mental state and behaviour significantly deteriorated following
each transfer of care.
h) Record keeping – The panel was concerned to note that that despite the
integration of mental health social workers into CMHTs to work alongside health
professionals, it seemed that the recording systems of health and social services
remained distinct: social services using SSIDs 96 and health their own recording
system. Thus, a new care coordinator from a different discipline (for example a
CPN who took over from a social worker) would not record on the same system.
If this is the case, then the continuity of record keeping is broken, there is the
potential for information being ‘lost’ between the systems and thus of other
professionals being unaware of what may be highly significant events. The
panel also heard that, because the CMHT office was shut outside normal office
hours, the CRT was unable to access the CMHT notes, or could only do so with
difficulty. It is hard to understand how such an obvious problem had not been
anticipated and dealt with, leading as it did to a situation identified elsewhere in
this report of services responding to Louisa Ovington as though each
presentation were new: having a snapshot of her difficulties rather than a
longitudinal view, or at the very least having some documented context in which
to deal with her.
96 Social Services Information Database