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

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CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS 150 It would seem from the panel’s experience in reading and hearing the evidence that there is a degree of scepticism or mistrust between some of these services; for example, criticisms were voiced about the police or Crown Prosecution Service (CPS) 102 being reluctant to prosecute offences committed by patients in hospital, which would be pursued if the offender were in the community; and the police remarked that the issue of medical confidentiality bedevils attempts at information sharing. The panel accepts that this is a difficult issue, but would point out that the principle of confidentiality has to be weighed up against the need for public protection. If there were ever a case where information sharing and a joint approach were essential, this was it. Observations to the SHA in relation to the police and probation services: The panel does not believe it would be appropriate, or welcome, to make recommendations for action to either the police or probation service, since, although they have cooperated fully with the investigation, they have had no part in commissioning this report. However, the panel expresses the respectful wish that the SHA should communicate the following suggestions to the police and probation service, which it hopes the two services will regard as helpful and constructive in furthering what must be a shared aim of reducing risk to the public as well as promoting an understanding of mental health issues suffered by offenders: • Durham Constabulary should establish and maintain, by whatever means are appropriate, a direct and formalised channel of communication between themselves and the mental health services within the Durham police area. Where the police are aware that an offender has mental health issues they should establish whether the offender is subject to the CPA, establish the identity of the care coordinator and ensure that the offender’s interactions with the police are reported to the care coordinator. • The police should wherever possible, attend case conferences when invited and care coordinators should ensure that where there is any suggestion that the client is involved with the police, a police presence, or, if not possible, a brief written update on police involvement, is requested and the police should as far as possible, comply with this request. • The two preceding paragraphs are equally applicable to the probation service where it is involved with a client. • The probation service, which seemed, from the information before the panel, to be more accustomed than the police to (at least) informal communication with the mental health services, should nonetheless review 102 Crown Prosecution Service
their procedures for formal contact and sharing information. They should ensure that when they are supervising a client with known mental health or drug and alcohol problems, there is a formal system in place for communication with the mental health services, so that information can be shared both ways. • No CO with a condition of psychiatric supervision should be made unless the probation service has (after consultation with him/her) identified the supervisor and informed the court of his/her identity. The court service should be invited by the probation service to consider revising its form to include the name and professional details (address and discipline) of the supervisor in the order and the probation service locally should amend its procedures to ensure that the probation officer understands that it is his/her responsibility to manage that condition and establish procedures by which this is done in every case. vii. Policies and procedures Several policies and procedure documents were received which helped the panel to understand the remit and workings of the numerous teams with which Louisa Ovington came into contact. The standard of the content and presentation varied considerably and it was not always possible to ascertain when they were produced, by whom, for which organisation and on what date they should be reviewed. It may be that as a result of the recent trust mergers many documents have eluded the archives and therefore were not retrieved. • Recommendation 27. Trusts should ensure that all policies include the production and review dates; the author; the organisation to whom it relates and are archived in a system, preferably electronic, where easy access is available. viii. Records CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS The panel found that most of the health records examined were reasonably comprehensive, some more than others. However there was much more variation in the standard of organisation of the hospital records: those from Edinburgh, Winterton, the Tony White Unit, St Nicholas’ Hospital and Kneesworth were well organised and easy to follow, (although Kneesworth had no section covering the hospital social work department’s involvement), whereas the records from Hartlepool General Hospital and Darlington Memorial Hospital were not: little logic or method seemed to have been applied to how they were set out and this made it hard to see clearly what had happened during Louisa Ovington’s periods as inpatient. 151
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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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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 and 144: • Recommendation 16. Trusts shoul
Page 145 and 146: f) Use of “talking therapies” C
Page 147 and 148: professional who had seen her withi
Page 149: i) Joint working CHAPTER 9 - CONCLU
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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Lousia Ovington independent investigation report ... - NHS North East

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