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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
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• Recommendation 3. Formal care planning meetings, involving current
and future care providers, must be held prior to a patient being
discharged from hospital and prior to any event that is known to have
the potential to result in the patient being discharged (in this case, the
expiry of the Section 38 order).
• Recommendation 4. If a patient is admitted to an independent hospital
outside the local area, progress reports are sent to the care coordinator
and the funding authority at least every three months.
• Recommendation 5. Care coordinators may leave their posts at short
notice. The panel accepts that this and difficulties in replacing staff, may
militate against good handovers between care coordinators. However,
trusts should ensure that transfers of care are agreed to in writing, that
the new care coordinator accepts that he/she is taking on responsibility
for the patient and that CPA documentation includes a full and up to
date historical summary that can be handed over to the new care
coordinator.
• Recommendation 6. Trusts should give serious and urgent consideration
to implementing a unified computerised record keeping system on which
all entries relating to the day to day working with a client are recorded,
by all mental health professionals.
• Recommendation 7. Trusts should ensure that a thorough needs
assessment is carried out for both carers and “significant others” to
properly inform risk assessments and care plans.
ii. Risk assessment
Past behaviour is the best predictor of future behaviour. An accurate and complete
history is therefore essential as the foundation for an effective risk assessment and
management plan.
There was little evidence of formalised risk assessment within health and social care
that was meaningful in the context of Louisa Ovington’s repeated threats of violence
and abuse including serious threats against Maurice Hilton. Several local models were
in use but the impression given was that they were completed on an ‘ad hoc’ basis
with little or no valid contribution to the overall treatment programme.
The only other agency that used formalised risk assessments routinely was the
probation service which used its standard, nationwide OASys tool. This could at times
have usefully informed health and social care risk assessments, or been used in multi
agency working, particularly in relation to MAPPA, but there was no evidence of this.