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

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CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS 152 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.
CHAPTER 9 – CONCLUSIONS AND RECOMMENDATIONS This investigation was established to examine the health care and treatment afforded to Louisa Ovington. Nonetheless, whatever deficiencies the panel may have identified, it should never be forgotten that it is Louisa Ovington who was actually responsible for Mr Hilton’s death. 153
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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
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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 and 150: i) Joint working CHAPTER 9 - CONCLU
Page 151: 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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Lousia Ovington independent investigation report ... - NHS North East

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