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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 22 57. On 22 December 1998 a review meeting was held at the Tony White Unit to consider whether she could be discharged (concluding that she could not) and aftercare arrangements if she were to be. A social worker, Social Worker 1, who had known Louisa Ovington and the family for some time and had had discussions with them, said that Louisa Ovington was extremely damaged and expressed the fear that Louisa Ovington would at some point go on to commit a serious crime as her father had. Her great uncle had expressed similar fears, as well as fears for his own safety. 58. Further discussions had taken place as a result of which Consultant 9 agreed to take Louisa Ovington on the medium secure forensic ward at St Nicholas’ Hospital. There was discussion as to which section of the Mental Health Act would be most appropriate. Consultant 9 told the panel that he favoured the use of Section 38 30 - an order lasting 12 months permitting assessment during ongoing court proceedings. This would, he told the panel, have kept her in hospital and obliged the court to remain involved. If she had been detained under Section 37/41 and the proceedings against her had been discontinued, there was a chance she could have successfully appealed against the Section 37 and been discharged by a Mental Health Review Tribunal. There was no such appeal possible against Section 38. His clear view was that the matter should ultimately be disposed of with a Section 37/41. 31 Consultant 5’s view was that by December 1998 it was no longer helpful for her to be treated at the Tony White Unit; the important thing was for her to be transferred somewhere where she could have exposure to a wider range of treatments. He therefore supported Consultant 9’s recommendation of a Section 38, so that Consultant 9 would accept her at St Nicholas’ Hospital. Nonetheless Consultant 5 told the panel that he would have preferred to recommend that Louisa Ovington be either continued on Section 37 or made subject to a Section 37/41. 59. Despite the immense difficulties that the staff faced whilst looking after Louisa Ovington on the Tony White Unit, there is evidence within the notes of the staff doing their best to support her. During this admission Louisa Ovington had numerous visits from family members and was visited by her father who contacted the ward through his supervisor at Edinburgh prison, asking if he could visit her. (Louisa Ovington’s feelings towards her father appeared to fluctuate: on 22 August 1998 she said she intended to kill him when she was 20 years old.) Louisa Ovington’s religious needs were met by her having visits from Catholic priests on several occasions, as and when she requested this. Louisa Ovington was given occasional escorted leave in the grounds of the hospital and to town. Staff reported however that at these times she was quite excitable and often exhibited inappropriate behaviour. On 24 December 1998 Louisa Ovington was supported by staff when she wanted help to write to the Mental Health Act Commission 32 to inform them of her discontent about being at the Tony White Unit. 30 See Chapter 8 31 See Chapter 8 32 The Mental Health Act Commission was the body charged with monitoring the use of detention under the Mental Health Act. It has now been replaced with the Care Quality Commission.
60. As was common in 1998, there were few formalised risk assessments. Staff Nurse 1 told the panel: “We very much worked on a sort of activities of daily life model ... we didn’t have a specific risk assessment at that time on the unit, it was very much down to the experience of staff. And as part of the care plans, you know from the initial assessment … through observing the actions and the outcomes of those actions then the level of risk would be assessed and the care plan would be updated or discontinued or a new plan written.” COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS Louisa Ovington was admitted to the Tony White Unit from Low Newton after the symptoms of psychosis failed to abate with medication. It was clear from fairly early on that the clinical view was that the unit was not an ideal setting in which to treat Louisa Ovington. On admission Louisa Ovington exhibited florid symptoms of mental illness; as time went on the symptoms abated but her persistent, extremely disturbed and aggressive behaviour continued and she clearly presented a major challenge in a unit which, although it was a PICU, was not designed for long term treatment of persons with personality disorders. The nursing and medical records are full and detailed but effective intervention was limited by a lack of appropriate resources and by the fact that as a result of the risks she posed to the staff, containment and transfer to more appropriate surroundings, rather than any more elaborate therapeutic plans, were uppermost in the minds of those treating her. The panel noted the reluctance of the clinical team to involve the police and to charge Louisa Ovington for her behaviour, despite the extreme level of her aggressive assaults. They were told by Consultant 5 that although there is the potential in principle to charge people for criminal damage to fittings or aggression towards people within hospital, in his experience the police are terribly reluctant to pursue these and if charges are brought the Crown Prosecution Service (CPS) drops the cases. Sister 1 told the panel that nonetheless the hospital had “good relations with the police” because they would come in with the sniffer dogs on a fairly regular basis to keep the drug problem on the open wards down to a minimum. 23
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 and 18: 20 May 1998 to 12 January 1999 CHAP
Page 21: CHAPTER 1 - NARRATIVE OF KEY DATES
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
Page 71 and 72: 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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