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

CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS
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The GPs’ records were clearly based on the ‘Lloyd George’ system and were somewhat
sparse, but may have accurately reflected their relatively minor degree of involvement
in her mental health care.
The social work records were reasonably comprehensive and easy to follow although
her child and adolescent social services records could not be found. Her education
records had been destroyed, which was unfortunate.
The records from the CMHT and CRT were also reasonably comprehensive and easy
to follow; the addictions services’ recording was somewhat sparse, perhaps reflecting
Louisa Ovington lack of engagement.
There was a notable lack of CPA documentation throughout the records: this may
have reflected either the relative infrequency of CPA planning or meetings, poor
recording, or poor storage of documents. The CPA office for the trust area, which
should retain all records, had a very limited archive of CPA documentation relating to
Louisa Ovington.
As has been remarked on earlier in this report, there was a complete absence in
any of the records of any comprehensive and regularly updated summary of Louisa
Ovington’s history which would have informed clinicians who took over her care.
• Recommendation 28. Trusts should ensure that all professionals keep up
to date, contemporaneous notes that are organised methodically and in
such a way that they are readily accessed (by those authorised to do so)
and easily understood.
• Recommendation 29. A comprehensive, regularly updated chronological
history should be maintained which is accessible by all those (authorised
to do so) who are dealing with the patient.
• Recommendation 30. Where trusts are commissioning services from
independent sector providers, trusts should ensure that the practice of
those providers complies with those recommendations.
• Recommendation 31. The panel is concerned that many of the
above conclusions and recommendations echo those made in other
investigation reports, therefore consideration should be given to the use
of such reports for training purposes. Additionally, the panel hopes that
this report is widely disseminated across agencies.