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

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CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS 144 • 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.
f) Use of “talking therapies” CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS The panel could find no evidence that anyone ever did any significant work with Louisa Ovington regarding her childhood experiences. She appears not to have been offered psychological help during her childhood; she did not engage with psychologists whilst in hospital; she did no formal work on this in the community. The panel accepts that Louisa Ovington was reluctant to engage in psychological work. Nonetheless, the panel considers that significant opportunities to attempt treatment of Louisa Ovington were missed: • She could have been referred to CAMHS following the death of her mother. • She saw a private counsellor when she attended Peterlee College, but no attempts were made to refer her for counselling through the NHS when she began to come into contact with adult mental health services. • There was little opportunity for her to engage in psychological work when she was admitted to the PICU at the former County Hospital in Durham. When she moved on to Newcastle and then to Kneesworth House, psychologists carried out assessments, but they did not tackle the more difficult task of engaging her in therapeutic treatment. • A year after her discharge, Social Worker 4 tried to arrange some formal counselling for her. At this point Louisa Ovington was ambivalent about engaging in this work. It took at least six months for an agency to indicate that they would be willing to work with her. By this time, she appeared to have lost any interest that she had had in doing this work and she did not approach the agency herself as they had requested. Social Worker 4 then attempted to have Louisa Ovington referred for psychotherapy – but again it took over six months for her to be seen. It appears that little effort was then made to encourage her to take up the option of doing this work, on the grounds that Louisa Ovington was apparently only looking for symptom relief. Subsequently, she was never referred for any form of therapy, despite various staff discussing the potential value of this for her. • The panel was told that, at that time, there were no specific services for people with personality disorders and specialist treatments such as dialectical behaviour therapy were unavailable. Whilst it might have been difficult to engage Louisa Ovington in psychodynamic therapy and the process of it might have been very disturbing for her, it was unfortunate that it took so long for her to be referred 145
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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
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CHAPTER 4 - THE CARE PROGRAMME APPR
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CHAPTER 4 - THE CARE PROGRAMME APPR
Page 93 and 94: CHAPTER 4 - THE CARE PROGRAMME APPR
Page 95 and 96: 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 and 140: Some of the risk assessments from a
Page 143: • Recommendation 16. Trusts shoul
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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