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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 38 • There was no record of the home authority being involved in discharge arrangements or Consultant 9 having been consulted or even informed prior to discharge. The effect of this was that there was no opportunity for a well planned handover to the home services. • Forensic services should have been involved ( they were the agency that referred Louisa Ovington to Kneesworth House) and it was made clear to the panel that in view of Louisa Ovington’s history they were expecting and willing to be involved with her post discharge. • It is regrettable that Consultant 9 (the referring consultant) was not contacted when Louisa Ovington’s discharge from Kneesworth House was first considered. He told the panel that his team would have been able and willing to provide follow up in the community. Louisa Ovington was known to have difficulties with engagement. She was much more likely to engage with a team she already knew than with people with whom she had no prior relationship. • The rationale for Louisa Ovington not meeting the criteria for further detention was not clearly explained. There was a contradiction in the fact that the clinical team at Kneesworth House expressed the view that Louisa Ovington was not suffering either from mental illness or from a personality disorder yet were taken aback and concerned when the home community team accepted the probation view that since there was no mental illness there was no need for probation with a condition of psychiatric treatment. • In March 1999, government policy was published which defined the new arrangements for Effective Care Co-ordination 46 . This drew together the previous arrangements for the CPA and the previous arrangements for care management which had been the responsibility of social services departments and required staff to work together to ensure that effective discharge arrangements were in place particularly for those under enhanced CPA ( which Louisa Ovington was). Under these terms the care planning prior to discharge fell well short of what might have been expected. The home social services team was clearly concerned about this and a full meeting was held on 24 January. However it appears that of the important elements of the care plan none was effectively implemented: Louisa Ovington did not see her Key Worker (Social Worker 2); she did not wish to be referred to drug and alcohol services; she was not assessed by the CPN service; no referral was made to Stonham Housing and she did not attend any outpatient appointments with Consultant 12. 46 See Chapter 4
• Consultant 9,in his evidence to the panel, emphasised the importance of good quality handovers i.e. the importance when a patient moves from one service to another, of assembling as much information as possible about the person for the benefit of the service taking over care. That clearly seems to have been the case in the handover from St Nicholas’ to Kneesworth, when Registrar 1 collated a very significant amount of information. It was not matched by the handover from Kneesworth. May 2000 to January 2003 CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 107. In May 2000 the case was allocated to Social Worker 4, a mental health social worker from South Durham (Spennymoor) who made immediate attempts to locate Louisa Ovington. He first met her on 30 May 2000. Louisa Ovington’s cousin had told Social Worker 4 how concerned she was about Louisa Ovington’s presentation - that she had been shouting and screaming down the phone causing her cousin to believe that her mental health had declined and that she might pose a threat to her and her family. When Social Worker 4 met Louisa Ovington he wondered whether she was under the influence of illegal substances. 108. Social Worker 4 was Louisa Ovington’s social worker from May 2000 until February 2003. During this time there is clear evidence that he went to a great deal of trouble for Louisa Ovington, whose life was chaotic. He had frequent and regular contact with Louisa Ovington and with professionals on her behalf; he accompanied her to meetings and helped her deal with innumerable issues including benefits, housing and employment as well as issues relating to her lifestyle, offending and mental health. He assisted her in dealing with communications from her father, who had been released from prison. He referred her to the addictions team. He discussed (to an extent) her childhood experiences with her. He went to considerable lengths to arrange meetings to discuss her psychiatric care; tried to find out who was the responsible psychiatrist; attempted to arrange for her to see a psychologist and a CPN. He seems to have built a relationship with her; certainly she kept in touch with him as well as vice versa. He told the panel: “The … focus in my work at that time was centred on my concerns for Louisa Ovington’s psychological state. She was very good at putting across that she was okay and I think despite the several assessments she did have, psychological, psychiatric or whatever… at the time people did not pick up what this girl was going through.’’ 39
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 and 32: visit to see him. A little later, o
Page 33 and 34: 93. The final report from the psych
Page 37: surprised and told the panel that h
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
Page 87 and 88: CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 89 and 90:
CHAPTER 4 - THE CARE PROGRAMME APPR
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
The essence of CPA is to ensure car
Page 99 and 100:
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
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CHAPTER 8 - USE OF THE MENTAL HEALT
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Page 131 and 132:
Page 133 and 134:
Given the multiplicity of agencies
Page 135 and 136:
CHAPTER 9 - CONCLUSIONS AND RECOMME
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Page 139 and 140:
Some of the risk assessments from a
Page 141 and 142:
Page 143 and 144:
• Recommendation 16. Trusts shoul
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f) Use of “talking therapies” C
Page 147 and 148:
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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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
Page 164:
INTRODUCTION 28 North East Strategi
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