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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
146
and subsequently for the assessment for psychological work to take place, as any
motivation she had for doing the work appears to have been lost during the
intervening period.
• Recommendation 21. Trusts should review the provision and availability
of “talking therapies”, including dialectic behavioural therapy in the trust
area and encourage clinicians to actively consider whether the needs of a
patient should be addressed by psychotherapy or psychology. This is
particularly important where a patient (such as Louisa Ovington) has
suffered some form of extreme childhood trauma.
g) Referral procedures
The panel noted that on a number of occasions there was confusion about how
referrals to services should, or could be made.
Examples were:
i. In April 2001, Social Worker 4 was attempting to get psychological support for
Louisa Ovington. It appeared to the panel remarkably difficult for him to get
someone to refer her, as he kept being advised to discuss the matter with
different people. It was unclear why he could not refer her to the psychology
department himself. The referral to Psychotherapist 1 was finally done by
Consultant 5 in July 2001. 98
ii. At around the same time, Social Worker 4 was trying to get Louisa Ovington
referred to CPN services, which should have been done after her discharge from
Darlington Memorial Hospital in February 2001. He seemed to be unable to
effect this referral and again, the panel was unclear about why. 99
iii. In early 2002 there was no clarity at all about who was responsible for
overseeing Louisa Ovington’s psychiatric care. Social Worker 4 was attempting to
find out about her current mental health. After several calls, first to Consultant
14 (who he was informed had left several months earlier) and then to Consultant
13, to no effect, he was told by Consultant 13’s secretary that if he wished to
access Louisa Ovington’s outpatient records, he should ask the GP to get hold of
them.
iv. On 10 June 2004 the emergency duty social worker received a referral from
Louisa Ovington’s landlady about Louisa Ovington’s extremely disturbed
behaviour. The social worker rang the GP, who told her to contact the CRT, who
refused to take a referral from the social worker, as it ‘needed to come from a
98 Chapter 1 paragraph 126
99 Chapter 1 paragraph 118