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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
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• Recommendation 18. Whilst not all patients who have been in medium
secure hospitals require ongoing support from forensic services,
mechanisms should be put in place to ensure that such patients are
discussed with the local forensic services when they are discharged into
the community. Ideally, the forensic services should be invited to attend
the pre-discharge care planning meeting, but if this is not possible, then
the treating community team should subsequently discuss the case with
their local forensic team.
e) Use of addictions services
From at least 1996 onwards, the misuse of drugs and alcohol had a seriously
harmful effect on Louisa Ovington’s mental health and impacted on the safety of
others. She was intoxicated with alcohol when she killed Mr Hilton. In the panel’s
opinion this issue was inadequately addressed. Some attempts were made to
tackle it, both whilst she was in the community and also as an inpatient. She
was discharged from Kneesworth before this work could be completed and she
did not properly engage subsequently in the community. Little attempt seems
to have been made to motivate her to do this. Furthermore, the panel was
concerned to note that the staff working with her appeared to simply accept
whatever Louisa Ovington told them about her drug and alcohol use. The
community addiction services worked independently from the mental health
teams. There seemed to be poor integration and information sharing between
adult mental health services and addiction services and the addiction services
appeared to have seen their role purely as dealing with the immediate problem
of Louisa Ovington’s drinking and drug use, rather than exploring what lay
beneath it, or what its consequences were both in terms of her own health and
the safety of others. The panel is concerned that, in cases, such as this, where
patients are subject to CPA, addiction services are not part of the CPA process
and are not incorporated into the mainstream community mental health services.
• Recommendation 19. Trusts should endeavour to improve the joint
working between the addiction services and the adult mental health
services, with sharing of information and collaborative care coordination.
• Recommendation 20. Alcohol services often stress that patients need to
engage with them on a voluntary basis. However, this does not preclude
the need for these services to make every effort to motivate the patients
to engage. Staff working with this client group should be trained in such
techniques and receive regular supervision.