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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 32 89. A nursing progress report, prepared for that meeting, recommended further monitoring and observations without medication, work on Louisa Ovington’s antisocial behaviours and continuation of scheduled psychology, drama therapy, education and substance abuse sessions. Assistant Psychologist 2 (a graduate with no previous clinical experience) had a session with Louisa Ovington on 22 December 1999 and noted then that she was planning to work on drug issues in future sessions after the Christmas break. Thus it seems that the nursing and psychology staff did not feel that they had concluded their work at this point. 90. However three days later on 10 January Consultant 11 told Louisa Ovington that she would be recommending instead a probation order with a condition of psychiatric treatment. There was no explanation in the notes for this change but Consultant 11 when interviewed told the panel that “she thought it was likely to have been partially influenced by Louisa Ovington’s desperation to get out and partly by the psychology staff feeling that there was little point in keeping Louisa Ovington in hospital as they were unlikely to be able to make progress with her.” 91. Because of the imminence of the expiry of the Section 38 order two days later there was no time for any properly planned discharge process. Louisa Ovington’s cousin had offered Louisa Ovington a place in the home she shared with Mr Hilton and the children from each of their relationships. 92. Consultant 11 produced a report for the court hearing on 12 January 2000 that set out the results of the psychological assessments. It said that Louisa Ovington had ‘characteristics’ of antisocial and borderline personality disorders but did not meet the criteria for a major personality disorder; that there were no signs of mental illness and that thus she did not fit the criteria for a Section 37 order. Consultant 11 told the panel that at the time she accepted the psychologists’ view as she regarded them as expert in the field of psychological assessment and deferred to that expertise. COMMENT The panel noted that Louisa Ovington was only withdrawn from medication for a few weeks prior to being discharged from Kneesworth and wondered whether this was a sufficient length of time in which to assess whether she required medication. Consultant 11 told the panel that she would have liked to have had the opportunity to observe Louisa Ovington drug free for longer.
93. The final report from the psychology department post dated Louisa Ovington’s discharge in January 2000. It noted that: • External factors that appeared to have played a part in her psychotic breakdowns included her drug use, relationship instability, a drug using peer culture and a lack of purpose and direction in her life. • Louisa Ovington had an ‘underlying antisocial strand’ but that it had not been possible to understand this due to her reluctance to explore this in any depth. • She was ‘not ready’ to engage in a community based drugs rehabilitation programme or psychodynamic psychotherapy, commenting: “She will only explore these things when she is ready (if ever) and when the pain of not finding out about herself is greater than the pain of doing so.” 94. Consultant 11’s report recommended a probation order with conditions of both treatment (follow up by local services) and residence. Whilst Consultant 11 was under the misapprehension that Louisa Ovington was not entitled to Section 117 aftercare 39 , nonetheless she suggested that as a matter of good practice there should be a care planning meeting. 95. On 12 January however Louisa Ovington was discharged from Kneesworth House. She attended Peterlee Court and was bailed (to allow for the preparation of a pre-sentence Probation report) to her cousin’s address. Prior to her departure there had been no discharge planning meeting, no CPA/ Section 117 meeting 40 and no coordinated consideration of the future, apart from an acceptance that Louisa Ovington would be able to reside with her cousin and Mr Hilton. COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS This period in a specialist unit (in the private sector) for personality disorder may have identified some of the issues that needed to be addressed and the notes appeared to suggest a number of coping strategies but there was little evidence of a robust treatment package. There was no evidence of ongoing or formalised assessment of the risks Louisa Ovington posed. 39 See Chapter 8 40 See Chapter 8 33
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 and 28: women. Registrar 1 prepared a very
Page 29 and 30: 77. One of the major components of
Page 31: visit to see him. A little later, o
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
Page 83 and 84:
CHAPTER 2 - EVALUATION OF THE HEALT
Page 85 and 86:
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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Page 95 and 96:
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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
Page 157 and 158:
LIST OF RECOMMENDATIONS • Recomme
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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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