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

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LIST OF RECOMMENDATIONS 158 • 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. • 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. ADDITIONAL 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.
LIST OF RECOMMENDATIONS • 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 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. 159
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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
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DS1 told the panel bluntly that, in
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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 and 156: LIST OF RECOMMENDATIONS • Recomme
Page 157: LIST OF RECOMMENDATIONS • Recomme
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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