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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 14 14. Louisa Ovington was reviewed in the outpatient’s department at Hartlepool General Hospital and Peterlee Health Centre on five occasions during 1996. She was also seen regularly by CPN 1. Her medication was adjusted from time to time. She continued to accept intramuscular antipsychotic medication but the frequency of administration of doses was reduced over the course of the year and she used the oral medication intermittently. Up until December 1996 she appeared to be doing well: she was doing an ‘A’ level course and living with her great aunt and uncle. 15. On 5 December 1996 she spent a night in police cells for breach of the peace. A Mental Health Act assessment was done but she was found not to be detainable. It appears Louisa Ovington’s behaviour at home had deteriorated; there had been an altercation in which knives had been involved and her great aunt and uncle temporarily refused to allow her to remain in their home. On 10 December she was seen at an urgent outpatient appointment at Hartlepool General Hospital. Consultant 6 concluded that her behaviour was anti social rather than psychotic in nature, despite concerns expressed by her college tutors and the CPN. Nonetheless two days later on 12 December 1996 she was admitted on a voluntary basis as an inpatient at Hartlepool General Hospital under the care of Consultant 2 for four weeks 8 . 16. A care planning meeting was held on 20 December 1996. Concern was raised that Louisa Ovington was due, in relation to the murder of her mother, to receive a substantial amount of criminal injuries compensation as she had reached 18. Social Worker 1 expressed concern that Louisa Ovington would not be able to manage this money and she wondered whether the Court of Protection should be involved, but this was not pursued. 17. On 9 January 1997 Louisa Ovington insisted that she wished to discharge herself. She agreed however to take leave instead. She returned the following day seemingly intoxicated by drugs. Urine testing was positive for opiates and amphetamines and she admitted to the use of amphetamines and cannabis whilst on leave. She was discharged because of this. Because the discharge was sudden there was no discharge care planning meeting, but she was discharged on antipsychotic depot medication 9 . 18. As her great aunt and uncle would not allow her to return to their home Louisa Ovington went to Edinburgh to stay with her mother’s sister for a few days but then returned. She attended three outpatient appointments and also saw CPN 1. Social Worker 1 had done an assessment of need and was visiting her at home. The social worker was concerned to hear from her that she was having unprotected sex, was abusing drugs and that she enjoyed deceiving her guardians. She also told the social worker that she was having a relationship with a male nurse from Hartlepool General Hospital. Social Worker 1 immediately reported this and subsequently the nurse was dismissed. 8 2nd admission to hospital 9 Slow- release antipsychotic medication given by injection.
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 19. On 6 March 1997, there was a one-day admission to Hartlepool General Hospital 10 on the recommendation of CPN 1 after Louisa Ovington had started using street drugs again and was hallucinating. She was discharged because she smoked cannabis on the ward. 20. Following this brief admission Consultant 7, who commented in a letter he wrote to her GP that Louisa Ovington was taking a “phenomenal” amount of cannabis, reviewed her in the outpatients’ department. Consultant 7 took her off the depot medication and commenced her on oral antipsychotics. His opinion was that all her problems were drug related and he was worried that her drug taking might produce a ‘schizophreniform’ 11 illness. There was some attempt to engage her by social services and CPN 1 (who was about to leave her post). A care planning meeting was held (in her absence) on 22 April 1997. Her guardians did not know where she was but it later transpired that in March 1997 she had moved to Edinburgh. 21. While in Edinburgh it seems that Louisa Ovington was in touch with her father, who was still in custody for the murder of her mother. At this time she met a man and entered into a form of marriage with him under Muslim law. She subsequently reported that she had married him to make her boyfriend jealous. The ‘marriage’ lasted three months. 22. She became psychotic in Edinburgh, possibly precipitated by her discontinuing her anti psychotic medicine; by the stresses of life, which included recent contact with her father, who had just been released from prison and by her unstable social situation. She was admitted to the Royal Edinburgh Hospital on 20 May 1997 12 and remained there for ten days during which time she settled on another anti-psychotic drug. She had a negative drug screen which supported the diagnosis made of schizophrenia, rather than drug induced psychosis. Her medication on discharge was chlorpromazine. 23. Knowing by then that she had moved to Edinburgh and because she was subject to CPA 13 , she was discharged from the Hartlepool and East Durham CPN service and the CPA manager in Hartlepool notified services in Edinburgh. The Edinburgh hospital staff arranged for her to be reviewed in outpatients. She missed two appointments and was therefore discharged. 24. Louisa Ovington returned to live with her great aunt and uncle some time after her discharge from Edinburgh. In early July 1997 she saw Consultant 6 (who thought the diagnosis at this point was ‘veering towards schizophrenia’) at outpatients at Hartlepool General Hospital and at Peterlee Health Centre and claimed to have seen the CPN 1 (although at the care planning meeting on 22 April 1997 the CPN had said she was leaving). Although there is mention of visual hallucinations and apathy in the records Louisa Ovington denied taking street drugs. The GP records indicate she was taking an antipsychotic daily from July 1997 to February 1998. There are no social services records of contact with her during the next few months and the police recorded no contact either. 10 3rd admission to hospital 11 A schizophrenia- type illness 12 4th admission to hospital 13 See Chapter 4 15
Page 1: REPORT TO THE NORTH EAST STRATEGIC
Page 5 and 6: Contents CONTENTS Page Preamble 6 I
Page 7 and 8: Introduction and terms of reference
Page 9 and 10: The panel met on 14 occasions, tota
Page 11 and 12: CHAPTER 1 - NARRATIVE OF KEY DATES
Page 13: This opinion was referred to by man
Page 17 and 18: 20 May 1998 to 12 January 1999 CHAP
Page 23 and 24: 60. As was common in 1998, there we
Page 27 and 28: women. Registrar 1 prepared a very
Page 29 and 30: 77. One of the major components of
Page 31 and 32: visit to see him. A little later, o
Page 33 and 34: 93. The final report from the psych
Page 37 and 38: surprised and told the panel that h
Page 39 and 40: • Consultant 9,in his evidence to
Page 43 and 44: 129. Although Louisa Ovington conti
Page 51 and 52: there was “some latitude” in th
Page 53 and 54: 61 14th offence 62 15th offence 63
Page 55 and 56: 176. Social Service staff did respo
Page 61 and 62: 78 21st offence 204. However Louisa
Page 63 and 64: hours. They did not have access to
Page 65 and 66:
210. CPN 2 also completed a risk as
Page 67 and 68:
Chapter 2 - Evaluation of the healt
Page 69 and 70:
CHAPTER 2 - EVALUATION OF THE HEALT
Page 71 and 72:
During Louisa Ovington’s first ad
Page 73 and 74:
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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The essence of CPA is to ensure car
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Chapter 5 - Involvement with police
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89 ibid The guidance states that th
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DS1 told the panel bluntly that, in
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and social care agencies. The panel
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CRO with a condition of psychiatric
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COMMENT The probation officer estab
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CHAPTER 5 - INVOLVEMENT WITH POLICE
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COMMENT CHAPTER 5 - INVOLVEMENT WIT
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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• South West Durham Mental Health
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CHAPTER 7 - PROVISION OF MENTAL HEA
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The policy changes were driven by t
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• Past psychiatric history; • S
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CHAPTER 8 - USE OF THE MENTAL HEALT
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Given the multiplicity of agencies
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CHAPTER 9 - CONCLUSIONS AND RECOMME
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Some of the risk assessments from a
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• Recommendation 16. Trusts shoul
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f) Use of “talking therapies” C
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professional who had seen her withi
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i) Joint working CHAPTER 9 - CONCLU
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their procedures for formal contact
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • The pol
Page 161 and 162:
Bibliography 1. Effective Care Coor
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INTRODUCTION 28 North East Strategi
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