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

• Recommendation 16. Trusts should review clinical practice to ensure, in
relation to psychometric tests, that they are only regarded as an adjunct
to clinical judgement to inform diagnosis. They should not, on their
own, be regarded as diagnostic instruments.
c) Personality disorder services
When Louisa Ovington was transferred to St Nicholas’ Hospital she was thought
to be suffering from a personality disorder (possibly psychopathic) and mental
illness (possibly schizophrenia or bipolar disorder). By the time she was
transferred on to Kneesworth House, there was less evidence that she was
suffering from a mental illness but staff were clearer that she was suffering
from a personality disorder. However, when she was finally discharged back into
the community there was still no clarity as to her diagnosis. The discharge report
from Kneesworth House stated that she had a “past history” of mental illness
and that she “could not be said to have a personality disorder”. Inconsistently,
the staff from Kneesworth House stated at Louisa Ovington’s post-discharge
care planning meeting that they felt she needed a condition of treatment
attached to a probation order, but they did not specify whether she needed
treatment for illness, personality disorder, or both. This lack of clarity about
diagnosis meant that no appropriate treatment plan was formulated. It appears
evident to the panel that thereafter Louisa Ovington’s mental health difficulties
were not taken so seriously and there was at times reluctance from services to be
involved with her because she was not regarded as mentally ill.
• Recommendation 17. The trusts need to be clear where the remit
for working with people with personality disorders falls. It needs to
be recognised that personality disorders can be as serious as illnesses
such as schizophrenia in terms of their negative impact on the individual
and the society around them. Appropriate, ideally specialist, services
need to be provided for such patients and the professionals working
with them need specific training and support.
d) Use of forensic services
CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
Louisa Ovington was followed up in the community by general adult mental
health services; the CMHT, the addictions services and, at times, the CRT. Given
her history of violence and her detention in conditions of medium security,
following her discharge from Kneesworth House she should at least have been
discussed with, if not taken on by, the forensic services, which the panel were
told would have been willing and able to work with her.
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