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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 18 36. Consultant 5’s opinion as expressed in his report for the Court dated 16 July 1998 was that Louisa Ovington was suffering intermittently from psychotic symptoms and that she was experiencing episodes of over-activity, aggression and distress punctuated by brief periods during which she was more controlled and communicative. He concluded that she suffered from both a mental illness and “to an extent” from a psychopathic personality disorder. He thought that the mental illness element was “quite strongly prevalent” at the time of her offending. 37. Consultant 5 recommended that the court dispose of the case by making an order under section 37 21 of the Mental Health Act to allow Louisa Ovington to be treated in a systematic way. He said that in the first instance a bed was available for Louisa Ovington at the Tony White Unit but that she might later require transfer into a different level of security because of the seriousness of the problems that she posed for nursing care (which later proved to be the case). 38. Consultant 7, a Locum Consultant Psychiatrist was asked to give the necessary second opinion as to whether a Section 37 Hospital Order would be appropriate and he therefore assessed Louisa Ovington at the Tony White Unit on 13 July 1998. He commented at some length on her extensive use of street drugs and said that he thought that when she committed the “index offence” 22 (the stabbing of the police officer, presumably regarded as the most serious of the cluster of offences with which she was charged) she was in an altered state of consciousness through the use of LSD, crack cocaine and magic mushrooms. He concluded that Louisa Ovington was suffering from a mental illness, describing the symptoms (for example, thought disorder, hallucinations, mood swings) and noting that at one point he thought she was going to attack him. He said she was “desperately in need of further treatment” and that due to her aggression this needed to be in conditions of medium security. He supported the recommendation that the court impose a Section 37 order. 39. On 17 July 1998 Peterlee Magistrates Court placed Louisa Ovington under Section 37 of the Mental Health Act in relation to the offences committed between 21 May 1998 and 20 July 1998. 23 40. On 3 August 1998 Sedgefield Magistrates Court did likewise in respect of the offences committed in February 1998. 24 41. She later appealed her detention to the Hospital Managers. The detention was upheld. There is no record of a Mental Health Review Tribunal. 25 42. While at the Tony White Unit Louisa Ovington had a full assessment of her physical as well as her mental health and was afforded ongoing physical health checks. 21 See Chapter 8 22 The main offence which led to the detention in hospital 23 2nd group of convictions 24 3rd group of convictions 25 See Chapter 8
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 43. The Tony White Unit notes are detailed and record the treatment given to Louisa Ovington for her mental illness - a combination of medication and nursing care. 44. Although Louisa Ovington’s sleep improved and there was some improvement in her presentation she was extremely distressed from time to time and her behaviour was extremely disturbed. She targeted particular members of staff and made serious threats of harm to them; she made formal complaints alleging staff brutality and sexual and physical assaults. She made malicious phone calls to the police; was sexually provocative, preoccupied and disinhibited; caused damage to the premises and assaulted and threatened staff and on one occasion another patient, as well as behaving aggressively to the more vulnerable patients. She attacked and bit one nurse on the inner arm, apparently because she did not like her mannerisms. By the beginning of November there had been 248 recorded incidents of aggression, confrontation, or hostility, including 36 physical attacks and 15 threats to kill. The level of her violence and aggression was so high that the police were involved and charges were pressed but this appeared to have little impact on her. Not all charges were proceeded with but in September 1998 she was charged with assault occasioning actual bodily harm - in respect of three assaults on nurses, including the bite injury. 26 She later said that during one of her assaults she had wanted to kill the victim. 45. At one point Consultant 5 commented that he believed that Louisa Ovington’s behaviour was a manifestation of psychopathic disorder. She herself commented to a nurse that she would “get away” with what she had done because she was “mad”. She expressed no remorse for some of the assaults. However in December 1998 she asked for anger management training as “her father had found it helpful”. 46. Louisa Ovington also self-harmed while she was at the Tony White Unit. She claimed to have taken an overdose of her contraceptive pill, poured hot coffee over her head (without sustaining injury), stabbed herself in the hand and made superficial cuts to her arm. 47. The nursing staff noted that she was very variable in her presentation and Sister 1 told the panel that they did not think that Louisa Ovington experienced true delusions or hallucinations, although she was “an unsettled character who thought the world was against her”. They thought that her behaviours stemmed from her personality problems. They did not think that she had access to, or was abusing, drugs on the ward. 26 6th group of offences 19
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 17: 20 May 1998 to 12 January 1999 CHAP
Page 23 and 24: 60. As was common in 1998, there we
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 37 and 38: surprised and told the panel that h
Page 39 and 40: • Consultant 9,in his evidence to
Page 43 and 44: 129. Although Louisa Ovington conti
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 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
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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
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CRO with a condition of psychiatric
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COMMENT The probation officer estab
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CHAPTER 5 - INVOLVEMENT WITH POLICE
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COMMENT CHAPTER 5 - INVOLVEMENT WIT
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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• South West Durham Mental Health
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CHAPTER 7 - PROVISION OF MENTAL HEA
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The policy changes were driven by t
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• Past psychiatric history; • S
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CHAPTER 8 - USE OF THE MENTAL HEALT
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Given the multiplicity of agencies
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CHAPTER 9 - CONCLUSIONS AND RECOMME
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Some of the risk assessments from a
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• Recommendation 16. Trusts shoul
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f) Use of “talking therapies” C
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professional who had seen her withi
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i) Joint working CHAPTER 9 - CONCLU
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their procedures for formal contact
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • The pol
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Bibliography 1. Effective Care Coor
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INTRODUCTION 28 North East Strategi
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