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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 28 was a predominantly male ward. Consultant 9 had no personal experience of Kneesworth and after a time lapse of ten years could not remember exactly what enquiries he had made, but he knew it to have a medium secure specialist personality disorder unit with males and females and told the panel that he had reason to believe it to be reputable and it was one of very few places that offered personality disorder services. The panel agrees that once the decision to transfer Louisa Ovington was made, it was reasonable on the information available to choose Kneesworth. It was also unfortunate that Louisa Ovington had to be moved several times. Her placements at the Tony White Unit and St Nicholas’ Hospital appear to have arisen through urgent necessity rather than choice. However, the move to Kneesworth House occurred when Louisa Ovington was over half way through a one year maximum detention under Section 38. The staff at Kneesworth House were therefore left with having to make their final decisions about her within less than five months of her admission there. Given Louisa Ovington’s complex presentation, this was bound to be difficult. Consultant 11 commented to the panel that the team at Kneesworth House could have done with longer to work on engagement with Louisa Ovington. As was the case at the Tony White Unit, few formalised risk assessments were carried out at St Nicholas’ Hospital - but the forensic psychologist told us that “individual disciplines would be collecting information, discussing, sharing it and then a general discussion at case conference would produce a view.” Registrar 1 told us: “I have to say that in the last ten years the process of risk assessments has changed beyond belief. It was simply a clinical judgment type of risk assessment in the past. The risk assessment process that is carried out these days bears no relation to good clinical practice in those days”. Consultant 9 told the panel that although he did not recommend that Louisa Ovington be detained under Section 37 (for the reasons given and further commented on in Chapter 8) prior to the transfer to Kneesworth House Hospital, he thought she met the criteria for a hospital order. Kneesworth House, Hertfordshire: 16 August 1999 to 12 January 2000 76. Louisa Ovington was admitted to Clopton Ward at Kneesworth House, Hertfordshire on 16 August 1999 36 under the care of Consultant 11, in order to assess the treatability of her mental disorder. It was anticipated by staff at St Nicholas’ Hospital (and by Consultant 10 at Rampton) that she would then need a further protracted period of time at Kneesworth for treatment. At the time of admission she was classified under the Mental Health Act 37 as suffering from mental illness. Kneesworth House is a hospital in the independent sector. Clopton Ward was a mixed gender ward dealing with personality disordered patients. The staffing was multi disciplinary in nature, including ward-based psychologists. 36 8th admission to hospital 37 See Chapter 8
77. One of the major components of Louisa Ovington’s treatment at Kneesworth was input from the psychology service, including assessment and treatment. Psychologist 2 and Assistant Psychologist 2 were the authors of the report. Psychologist 2 was a counselling, not a clinical psychologist; Assistant Psychologist 2 had a degree in psychology, but no previous practical experience. Her assessment was supervised by a clinical psychologist, Psychologist 3, who did not work on Clopton Ward. Assistant Psychologist 2 told the panel that from her recollection (nearly ten years ago) Psychologist 2 did not participate in psychology meetings and was somewhat isolated. Consultant 11 told the panel that Psychologist 2 was very forceful in making her views known. COMMENT The panel was unable to contact Psychologist 2. It is apparent that she left Kneesworth House about a year after Louisa Ovington did. Strenuous efforts were made to track her down without success; therefore comment that is made about the psychology assessments is made without the benefit of hearing her account. The panel was able to talk to Assistant Psychologist 2 but she was junior at the time, had little recollection of Louisa Ovington after such a long time and was unable to clarify many of the issues. 78. Psychological assessment sessions were carried out by Psychologist 2, in which Louisa Ovington’s history was explored. She was, by the fourth session, described as participating well, although there were also remarks about her being guarded and “closed off”. Although the assessment sessions noted that Louisa Ovington had nightmares relating to guilt, death and punishment (presumably arising from her mother’s death) and was ambivalent about her father, these were not identified as issues to work on. COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS Consultant 11 told the panel that Psychologist 2 had concluded that it would be very difficult to engage Louisa Ovington in any work in relation to her mother’s death and her unresolved feelings about her father. 79. The assessment did identify drug use as an issue to work on and noted that Louisa Ovington attributed all her problems to this and “is blithely convinced she will have no difficulty avoiding drugs in the future” – but alcohol use was not apparently considered. At the end of the assessments Louisa Ovington agreed to start some individual work with Assistant Psychologist 2 relating to substance abuse/relapse prevention. 29
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 23 and 24: 60. As was common in 1998, there we
Page 27: women. Registrar 1 prepared a very
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
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
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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
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CHAPTER 4 - THE CARE PROGRAMME APPR
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Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
The essence of CPA is to ensure car
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Chapter 5 - Involvement with police
Page 101 and 102:
89 ibid The guidance states that th
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DS1 told the panel bluntly that, in
Page 105 and 106:
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
Page 127 and 128:
CHAPTER 8 - USE OF THE MENTAL HEALT
Page 129 and 130:
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Page 133 and 134:
Given the multiplicity of agencies
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CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 137 and 138:
Page 139 and 140:
Some of the risk assessments from a
Page 141 and 142:
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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
Page 151 and 152:
their procedures for formal contact
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Page 155 and 156:
LIST OF RECOMMENDATIONS • 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
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INTRODUCTION 28 North East Strategi
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