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

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List of recommendations 154 LIST OF RECOMMENDATIONS The panel recommends that North East Strategic Health Authority requires trusts to adopt the following recommendations: • Recommendation 1. Trusts should ensure that new CPA guidance is or has been implemented and that this is fully understood by staff and supported with intensive training. • Recommendation 2. Trusts should ensure that all patients subject to CPA have a designated care coordinator who should be responsible for following the patient throughout stays in hospital whether locally or further afield, within the NHS or within the private sector. It should be the responsibility of the treating hospital to ensure that care coordinators are invited to care planning meetings, and that they are kept informed about any impending significant changes to the plans. Where the patient has been placed outside the locality, the care coordinators should, in turn, ensure that other relevant professionals in the locality are informed of all developments. • Recommendation 3. Formal care planning meetings, involving current and future care providers, must be held prior to a patient being discharged from hospital, and prior to any event that is known to have the potential to result in the patient being discharged ( in this case, the expiry of the Section 38 order). • Recommendation 4. If a patient is admitted to an independent hospital outside the local area, progress reports are sent to the care coordinator and the funding authority at least every three months. • Recommendation 5. Care coordinators may leave their posts at short notice. The panel accepts that this, and difficulties in replacing staff, may militate against good handovers between care coordinators. However, trusts should ensure that transfers of care are agreed to in writing, that the new care coordinator accepts that he/she is taking on responsibility for the patient, and that CPA documentation includes a full and up to date historical summary that can be handed over to the new care coordinator. • Recommendation 6. Trusts should give serious and urgent consideration to implementing a unified computerised record keeping system on which all entries relating to the day to day working with a client are recorded, by all mental health professionals.
LIST OF RECOMMENDATIONS • Recommendation 7. Trusts should ensure that a thorough needs assessment is carried out for both carers and “significant others” to properly inform risk assessments and care plans. • Recommendation 8. Trusts should ensure that accurate and regularly updated risk assessments, using a reliable tool, are carried out, and that the results of these are incorporated into risk management plans. This should be supported by training and regular audit. • Recommendation 9. Trusts should review policies and ensure that there are up to date ‘lone worker’ or ‘home visit’ policies in place in each part of the front line services, that staff are aware of such policies, and aware of the procedures in place to implement them. • Recommendation 10. Where there are several agencies involved with a patient and one of those agencies (be it health, social care, probation, or police) has implemented or considered implementing a ‘lone worker’ or ‘home visit’ policy in relation to that patient, this should be communicated to the other agencies involved, either through the care coordinator, or through public protection arrangements. • Recommendation 11. Staff dealing with patients whose behaviour is clearly risky or potentially risky, who have a history of detention in hospital as offenders, or have had dealings with the criminal justice system for violent offences, need to know when, and how, it is appropriate to refer to MAPPA. The criteria and MAPPA referral procedures, external and internal to the particular organisation, should be made crystal clear to all mental health professionals, including doctors, working in front line services, should be part of any induction programme and a regular and compulsory part of ongoing training. The training need not be burdensome, lengthy or expensive. • Recommendation 12. Similarly, staff should be made aware of the potential for referral to MARAC, and to MAPVA, and clear about the criteria and procedures as set out above. • Recommendation 13. The panel recommends that the question of continuity of care is addressed; where possible, care should follow the patient, and where a patient moves within a reasonable distance, there should be no undue haste to enforce changes of service provider. 155
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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
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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 and 152: their procedures for formal contact
Page 153: CHAPTER 9 - CONCLUSIONS AND 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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