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

visit to see him. A little later, one of her cousins also died. It was noted that she
was appropriately affected by the bereavements, particularly in relation to her great
uncle.
86. During the five months Louisa Ovington remained at Kneesworth House there
was no evidence of psychosis and up to December 1999 her mental state and
presentation remained stable, in marked contrast to how she had been in the Tony
White Unit only one year previously, despite the fact that she had to cope with two
significant bereavements whilst she was there. She was compliant with medication.
Ward rounds took place on a regular basis and were appropriately recorded with few
problems noted.
87. She was given escorted leave, both to home and locally. All passed without
incident. She was well supported by the nursing staff. One noted that Louisa Ovington
told her that “she did not like people knowing too much about her business” this
being why she did not say much in ‘sessions’. In the few weeks leading up to her
discharge one or two incidents were noted on the ward, when she exhibited sexually
challenging behaviour and was emotionally unstable. At this time she had been taken
off Carbamazepine. The relationship between the deterioration in behaviour and the
cessation of Carbemazepine was not explored. At the point of discharge she was
considered not to be suffering from a mental illness.
COMMENT
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
The panel noted the apparent disparity between the nursing records and the
conclusion drawn at the ward round about the stability of Louisa Ovington’s mental
state when off medication. There were several potential reasons for the change in
Louisa Ovington’s behaviour: she was approaching another court appearance with
the possibility of being released; she will have been increasingly frustrated at being
detained in hospital; being provocative to staff, by being mildly badly behaved,
may have been a way of distracting them from talking with her about real issues of
concern such as how she was going to manage in the community if she was released.
88. Louisa Ovington was due to appear in court again on 12 January 2000. By
then she would have been on Section 38 for a year and consequently the Section
could not be further renewed. By that date therefore Consultant 11 had to make a
recommendation to the court regarding the final disposal of the case. But it is clear
that even just one week prior to the court hearing there was uncertainty amongst the
clinical team as to what that recommendation should be. After the New Year, on 7
January 2000, there was an MDT 38 meeting in which Louisa Ovington was told that
Consultant 11 would be recommending a Section 37 order.
38 Multi Disciplinary Team
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