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

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CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS 140 It was evident from the records and from what the panel was told by some witnesses that, in 2004, there was confusion, ignorance and perhaps an underlying lack of confidence, amongst some health and social care professionals about what avenues could legitimately be pursued when issues of public protection were raised. The issue was mentioned several times and although Social Worker 7 raised the matter specifically with probation on at least two occasions, on being rebuffed she did not pursue the matter. Despite the fact that it was perfectly reasonable of her to accept the view of the probation service (since they were part of the Responsible Authority), in her role as a representative of one of the ‘duty to cooperate’ authorities, she or her manager could have made the referral to the MAPPA agency themselves. Both the police and probation have acknowledged that they should have referred Louisa Ovington for MAPPA. MARAC (Multi Agency Risk Assessment Conference) and MAPVA (Multi Agency Protection of Vulnerable Adults) are two further frameworks for public protection, both introduced locally after Louisa Ovington killed Mr Hilton. (The panel does not know and has not investigated, whether Mr Hilton would have been categorised as a vulnerable adult). • Recommendation 11. Staff dealing with patients whose behaviour is clearly risky or potentially risky, who have a history of detention in hospital as offenders, or have had dealings with the criminal justice system for violent offences, need to know when and how, it is appropriate to refer to MAPPA. The criteria and MAPPA referral procedures, external and internal to the particular organisation, should be made crystal clear to all mental health professionals, including doctors, working in front line services, should be part of any induction programme and a regular and compulsory part of ongoing training. The training need not be burdensome, lengthy or expensive. • Recommendation 12. Similarly, staff should be made aware of the potential for referral to MARAC and to MAPVA and clear about the criteria and procedures as set out above. iv. Organisational structure It is unfortunate that during her ten year journey through the psychiatric services in the north east, Louisa Ovington was admitted to no fewer than five inpatient units. This excludes her inpatient episodes in Edinburgh and Kneesworth House. The resultant change of psychiatrists and other clinical staff would have done little to bring together her needs into a consistent and meaningful clinical management plan.
CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS It is recognised also that services in the Easington locality were not as well developed into the new millennium as they were elsewhere in the north east. A major investment programme was established through Easington PCT to enable the new services required by the Mental Health National Service Framework to be provided. While this was a welcome development it did produce a period of turbulence while reorganisation was taking place and this together with Louisa Ovington moving into new localities gave rise to a fragmented approach to her care. In particular, the following issues were noted: a) Staffing issues – The panel heard in evidence that recruitment and retention were major issues locally. This was more so with senior medical staff than other disciplines and it resulted in a number of temporary psychiatrists being appointed as locums. The number of times Louisa Ovington changed psychiatrists in addition to changes to care co-ordinators and a change of GP is noted elsewhere in this report. This picture was mirrored within other agencies and it is noted that Louisa Ovington was involved with at least seven probation officers during the period under review. The consequences of such major disruption to her management are clear. b) Team changes – while the new developments were welcomed - the arrival of new teams bringing with them new staff and enhanced inter-agency working - the benefits to Louisa Ovington’s care were less than clear. There should have been an opportunity for multi-disciplinary working with Louisa Ovington benefiting from a broader range of skills, but the reality was that staff continued to work in an un-disciplinary manner with little cross fertilisation of ideas. The CRT offered much in their operational policy but limited themselves in what they were able in practice to offer Louisa Ovington. There is little evidence of staff within the teams utilising the availability of peer review or clinical supervision to audit their clinical input to individual cases. What should have been an opportunity for ‘joined up working’ did not fully materialise. • Recommendation 13. The panel recommends that the question of continuity of care is addressed; where possible, care should follow the patient and where a patient moves within a reasonable distance, there should be no undue haste to enforce changes of service provider. • Recommendation 14. Trusts should take the opportunity to review the joint working arrangements within teams, to determine whether 141
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REPORT TO THE NORTH EAST STRATEGIC
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Contents CONTENTS Page Preamble 6 I
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Introduction and terms of reference
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The panel met on 14 occasions, tota
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CHAPTER 1 - NARRATIVE OF KEY DATES
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This opinion was referred to by man
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20 May 1998 to 12 January 1999 CHAP
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60. As was common in 1998, there we
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women. Registrar 1 prepared a very
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77. One of the major components of
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visit to see him. A little later, o
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93. The final report from the psych
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surprised and told the panel that h
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• Consultant 9,in his evidence to
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129. Although Louisa Ovington conti
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there was “some latitude” in th
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61 14th offence 62 15th offence 63
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176. Social Service staff did respo
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78 21st offence 204. However Louisa
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hours. They did not have access to
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210. CPN 2 also completed a risk as
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Chapter 2 - Evaluation of the healt
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CHAPTER 2 - EVALUATION OF THE HEALT
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During Louisa Ovington’s first ad
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Kneesworth House Louisa Ovington co
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The conclusion drawn by the psychol
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On 10 July 2001 Louisa Ovington att
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take part in several sessions of a
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COMMENT CHAPTER 2 - EVALUATION OF T
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CHAPTER 2 - EVALUATION OF THE HEALT
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 89 and 90: CHAPTER 4 - THE CARE PROGRAMME APPR
Page 97 and 98: The essence of CPA is to ensure car
Page 99 and 100: Chapter 5 - Involvement with police
Page 101 and 102: 89 ibid The guidance states that th
Page 103 and 104: DS1 told the panel bluntly that, in
Page 105 and 106: and social care agencies. The panel
Page 107 and 108: CRO with a condition of psychiatric
Page 109 and 110: COMMENT The probation officer estab
Page 111 and 112: CHAPTER 5 - INVOLVEMENT WITH POLICE
Page 113 and 114: COMMENT CHAPTER 5 - INVOLVEMENT WIT
Page 115 and 116: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 117 and 118: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 119 and 120: • South West Durham Mental Health
Page 121 and 122: CHAPTER 7 - PROVISION OF MENTAL HEA
Page 123 and 124: The policy changes were driven by t
Page 125 and 126: • Past psychiatric history; • S
Page 127 and 128: CHAPTER 8 - USE OF THE MENTAL HEALT
Page 133 and 134: Given the multiplicity of agencies
Page 135 and 136: CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 139: Some of the risk assessments from a
Page 143 and 144: • Recommendation 16. Trusts shoul
Page 145 and 146: f) Use of “talking therapies” C
Page 147 and 148: professional who had seen her withi
Page 149 and 150: i) Joint working CHAPTER 9 - CONCLU
Page 151 and 152: their procedures for formal contact
Page 155 and 156: LIST OF RECOMMENDATIONS • Recomme
Page 157 and 158: LIST OF RECOMMENDATIONS • Recomme
Page 159 and 160: LIST OF RECOMMENDATIONS • The pol
Page 161 and 162: Bibliography 1. Effective Care Coor
Page 164: INTRODUCTION 28 North East Strategi
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Lousia Ovington independent investigation report ... - NHS North East

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