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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 42 124. On or about 23 June 2001 Louisa Ovington assaulted Mr Hilton with a knife and self harmed by cutting her own neck (and reported that she had attacked her cousin). She was charged with a public order offence 50 and she appeared at court on two occasions and was bailed. The outcome of this case is not recorded. It would seem that probation, the domestic violence unit at Durham police, social services and the CPN service were informed. It is not clear who took what action as a consequence or how much communication there was between the agencies 125. Social Worker 4 convened a CPA on 10 July 2001 (which neither probation nor the GP was able to attend). The minutes were not available to the panel but it seems that Consultant 5 was present and agreed to take Louisa Ovington on and see her on a monthly basis. Social Worker 4 felt she was in a very volatile state. There were concerns about her father’s attempts to contact her. 126. On 13 July 2001 Consultant 5 referred Louisa Ovington for psychotherapy with Psychotherapist 1. (Unfortunately due to a combination of factors - the appointment letter going to the wrong address, Louisa Ovington not completing the paper assessments and only attending one appointment and delay, the conclusions were incomplete and were not available until the following June (11 months later). Psychotherapist 1 commented that on the information available she seemed to have made reasonable progress over the past two or three years. He did not think she was suitable for psychotherapy. 127. In August 2001 Louisa Ovington attended outpatients with a consultant whose name she could not remember. It was not Consultant 5. She only attended one appointment with him. After some confusion it seemed that she had attended with Consultant 14 at Peterlee Health Centre, but Social Worker 4 having tried to keep track of whom she was seeing was told in November 2001 that Consultant 14 had left and that Consultant 13 was her consultant. In early 2002 however, Social Worker 4 (who had been trying to access her notes, with great difficulty and had been told by Consultant 13’s secretary that if he wished to access her outpatient notes, he must do so through her GP) was finally told that Consultant 2 was now the consultant in charge of her care. (The panel could find no reference to Louisa Ovington having any contact with Consultant 2). 128. The CRO lapsed as at 3 December 2002. The identity of the psychiatric supervisor remained unclear (there is little reference to it in the probation notes). 51 She occasionally attended at outpatients where she saw several different psychiatrists. She only saw Consultant 5 once in outpatients in July 2001. 50 8th offence 51 See Chapter 6
129. Although Louisa Ovington continued to suffer from the same sorts of underlying problems (mental health, substance – mainly alcohol - abuse, pressure from her father), her overall situation remained reasonably stable throughout 2002 and she appeared to be attending some sort of college course. Social Worker 4 felt it was the right time to hand her over to her local CMHT in Easington (East Durham). Additionally he told the panel that because of a border reorganisation Louisa Ovington’s home address was no longer in his catchment area. Until that point Social Worker 4 told the panel, his team (Spennymoor, South Durham) had been purely a mental health social work team. Now the new CMHTs were multi disciplinary. Care was handed to Social Worker 5, who was a mental health social worker. Social Worker 4 tried to set up a CPA meeting so that the handover could be done in a planned and informed way, but the meeting was cancelled. Social Worker 4 visited Louisa Ovington on 28 January 2003 and explained what was happening. COMMENT Psychiatric organisation: It was evident to the panel from the records and confirmed by several witnesses that in this locality there were significant medical staffing issues in from 2000 to 2002. Louisa Ovington was notionally involved with eight different psychiatrists between January 2000 and December 2002. There was a series of locums, each staying in post only a matter of weeks or months. Consequently Social Worker 4 did not know who had consultant responsibility for Louisa Ovington. This, added to her own generally chaotic behaviour, made it understandable that Louisa Ovington did not engage with the psychiatric services. Medical continuity was further impaired by the fact that Louisa Ovington changed GP during this period. CRO: CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS The Community Rehabilitation Order carried with it a condition of psychiatric supervision. There was never any clarity about who would take responsibility for this, despite the fact that Consultant 5 had stated in his report for the court that he would be content to be the supervisor. He only saw Louisa Ovington once. Social Worker 4 repeatedly tried to find out who she was supposed to be seeing. Consultant 5 told the panel that whenever he made a recommendation for a condition of psychiatric treatment he would offer to be the supervisor but that it was “very seldom” that he was given written confirmation of this or any other details of the order. He was not given any certification of this sort following Louisa Ovington’s appearance in Court on this occasion and thus she fell through the net. 43
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 and 38: surprised and told the panel that h
Page 39 and 40: • Consultant 9,in his evidence to
Page 41: CHAPTER 1 - NARRATIVE OF KEY DATES
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: CHAPTER 4 - THE CARE PROGRAMME APPR
Page 93 and 94:
CHAPTER 4 - THE CARE PROGRAMME APPR
Page 95 and 96:
CHAPTER 4 - THE CARE PROGRAMME APPR
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
Page 123 and 124:
The policy changes were driven by t
Page 125 and 126:
• Past psychiatric history; • S
Page 127 and 128:
CHAPTER 8 - USE OF THE MENTAL HEALT
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Given the multiplicity of agencies
Page 135 and 136:
CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 137 and 138:
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
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INTRODUCTION 28 North East Strategi
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