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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
150. On 14 May 2004, during a session with nursing staff, Louisa Ovington talked
about the alleged rape and said that if she were to see the two men involved she
would stab them and was willing to go to jail as a result. Later that day she became
“very aggressive” towards Mr Hilton in an argument over money – after resolving this
they had a cup of tea together.
151. On 15 May 2004 Louisa Ovington requested her own discharge and was
permitted to leave “against medical advice”. She was discharged on no medication.
She was referred to the CRT who agreed to be involved until the CPA meeting on 18
May 2004 when their continued involvement would be discussed.
152. On 16 May 2004 Mr Hilton contacted the ward to say that Louisa Ovington
needed some follow up as she was not back to her usual self. CRT were contacted
and agreed to visit to assess her mental state.
153. A CPA meeting took place on 18 May 2004 on the ward. Louisa Ovington
attended. At the meeting she admitted she was unable to control her temper; that
alcohol was her main problem and that she was aggressive to her partner. It was
agreed that Louisa Ovington would be referred for anger management and to ESMI
(the local drug and alcohol service) and that a social worker was to be engaged. She
was to be seen in outpatients’. She was diagnosed as having a borderline personality
disorder and alcohol dependence syndrome. She was discharged on no medication.
154. No social worker was appointed. There is no evidence that she took up the
services although her GP wrote to the drug and alcohol service asking them to try to
engage her by seeing her at home. There was a CPA document, unsigned by Louisa
Ovington, dated 10 May 2004 which identified her needs as monitoring of mental
health through attendance at the CMHT offices (Merrick House, Easington) with
Staff Grade Psychiatrist 1 and education in relation to substance abuse through ESMI.
Increased alcohol use would be a risk factor and should be monitored.
155. A patient discharge form detailing the current management plan, diagnosis and
medication (none) was sent out by 26 May 2004. The discharge letter relating to this
admission was dated 9 July 2004.
156. On 17 May 2004 CRT 1 (from the CRT) visited Louisa Ovington at home and
told the ward that she noticed hostility and abuse towards her partner. The CRT had
only a fleeting involvement with her at that point since she was not regarded as high
risk nor was there thought to be a mental health issue, rather the main diagnosis was
alcohol related. They agreed to refer her to drug and alcohol services and for anger
management.
49