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

More documents

Recommendations

Info

LIST OF RECOMMENDATIONS 156 • Recommendation 14. Trusts should take the opportunity to review the joint working arrangements within teams, to determine whether appropriate opportunities exist for clinical supervision, peer and case review, and to instigate procedures if not. • Recommendation 15. The panel recognises the pressure that may force psychiatrists to rapidly admit a patient to hospital where there is an urgent need for treatment. However the appropriateness of the placement should be kept under close review, and the trust should ensure that the responsible psychiatrist is supported in finding an alternative placement when clinical need, or the safety of staff, is an issue. The trust should also ensure, wherever possible, that choice of hospital is motivated not by expediency but by matching the patient’s need to the care that can be offered. • Recommendation 16. Trusts should review clinical practice to ensure, in relation to psychometric tests, that they are only regarded as an adjunct to clinical judgement to inform diagnosis. They should not, on their own, be regarded as diagnostic instruments. • Recommendation 17. Trusts needs to be clear where the remit for working with people with personality disorders falls. It needs to be recognised that personality disorders can be as serious as illnesses such as schizophrenia in terms of their negative impact on the individual and the society around them. Appropriate, ideally specialist, services need to be provided for such patients, and the professionals working with them need specific training and support. • Recommendation 18. Whilst not all patients who have been in medium secure hospitals require ongoing support from forensic services, mechanisms should be put in place to ensure that such patients are discussed with the local forensic services when they are discharged into the community. Ideally, the forensic services should be invited to attend the pre-discharge care planning meeting, but if this is not possible, then the treating community team should subsequently discuss the case with their local forensic team. • Recommendation 19. Trusts should endeavour to improve the joint working between the addiction services and the adult mental health services, with sharing of information and collaborative care coordination.
LIST OF RECOMMENDATIONS • Recommendation 20. Alcohol services often stress that patients need to engage with them on a voluntary basis. However, this does not preclude the need for these services to make every effort to motivate the patients to engage. Staff working with this client group should to be trained in such techniques, and to receive regular supervision. • Recommendation 21. Trusts should review the provision and availability of “talking therapies”, including dialectic behavioural therapy in the trust area and encourage clinicians to actively consider whether the needs of a patient should be addressed by psychotherapy or psychology. This is particularly important where a patient (such as Louisa <strong>Ovington</strong>) has suffered some form of extreme childhood trauma. • Recommendation 22. Trusts should ensure that all mental health professionals and staff across the various services are clear about who can make referrals to any other branches of the services, including psychiatrists, psychology, forensic, CMHT services, CRT, AOT and what the mechanism for referral is. • Recommendation 23. Trusts should disseminate across the services the criteria established by each branch of the service for acceptance into, and exclusion from that service. • Recommendation 24. Trusts should review all policies, formal or informal, that prescribe general rules for discharge from services, and ensure that they are not applied in a formulaic way. Discharge should be dictated not by non attendance per se, or by self evaluation, or by rigidly applying service criteria, but by clinical need and an up to date assessment of risk. If a patient has repeatedly failed to attend appointments, careful consideration should be given to whether more active steps should be taken to ensure engagement. The care coordinator’s opinion should be sought, as he or she is likely to have a broader knowledge of the patient. • Recommendation 25. There should be programmes in place to ensure those working with patients with personality problems are appropriately trained in motivational interviewing and engagement techniques. • Recommendation 26. Trusts should ensure that appropriate channels of communication are set up between mental health services and all other agencies working with patients. Care programme meetings could be a forum for this. GPs should be invited to attend all such meetings. Where criminal justice professionals are involved with a patient, the CPA meeting should be used as an opportunity for liaison with and sharing of information between all the different agencies. 157
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 and 14:
This opinion was referred to by man
Page 15 and 16:
Page 17 and 18:
20 May 1998 to 12 January 1999 CHAP
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
60. As was common in 1998, there we
Page 25 and 26:
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 35 and 36:
Page 37 and 38:
surprised and told the panel that h
Page 39 and 40:
• Consultant 9,in his evidence to
Page 41 and 42:
Page 43 and 44:
129. Although Louisa Ovington conti
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
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 57 and 58:
Page 59 and 60:
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
Page 75 and 76:
The conclusion drawn by the psychol
Page 77 and 78:
On 10 July 2001 Louisa Ovington att
Page 79 and 80:
take part in several sessions of a
Page 81 and 82:
COMMENT CHAPTER 2 - EVALUATION OF T
Page 83 and 84:
CHAPTER 2 - EVALUATION OF THE HEALT
Page 85 and 86:
CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 87 and 88:
CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 89 and 90:
CHAPTER 4 - THE CARE PROGRAMME APPR
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
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 and 150: i) Joint working CHAPTER 9 - CONCLU
Page 151 and 152: their procedures for formal contact
Page 155: 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
show all

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

Create successful ePaper yourself

Delete template?

Save as template?