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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 52 iv. On 13 July 2004 she was fined £50 for being drunk and disorderly on 26 June 2004; 57 v. On 17 July 2004 she threw an object at a till in a public house and was charged with criminal damage; 58 vi. On 18 July 2004 she called 999 and reported that someone had tried to assault her (untrue); vii. On 19 July 2004 she climbed up a tree, claimed she was tied there, used foul language and had to be brought down by the fire brigade; viii. On 22 July 2004 she made several 999 calls to the police threatening to kill Mr Hilton. She was visited by the domestic violence officer and a constable and contact was apparently made with the mental health team (there are no details of which team), who apparently contacted Louisa Ovington; ix. On 24 July 2004 a 999 call was made reporting a disturbance at Louisa Ovington’s home; x. On 25 July 2004 she made a further 999 call reporting an assault for which there was no evidence; xi. On 25 July 2004 she was arrested, carrying a knife in a public place; 59 xii. On 26 July 2004 she was charged with criminal damage to her cell 60 . 166. On 30 July 2004 she made a “hysterical and foul mouthed” call stating she was going to “murder” Mr Hilton as he had been harassing her (the harassment consisted of him “passing a pleasantry” to her). 167. The police domestic violence worker reported to Durham social services that Louisa Ovington had said that she would kill her ex partner - that she had a knife, a gun and a sword and would not think twice about killing someone - and that she was frightened at how out of control she felt. 168. On 30 July 2004 a police inspector, accompanied by Social Worker 6 visited Louisa Ovington at home. They found her calm and rational, there was no evidence of weapons and they felt there was no cause for concern, although she did say she would kill Mr Hilton if he came to the house. She was advised to make use of the current support she had. COMMENT The panel was unclear as to what support this would have been, given that there was no active community mental health worker. 57 8th conviction 58 11th offence 59 12th offence 60 13th offence
61 14th offence 62 15th offence 63 16th offence 169. The following day CRT 1 visited Louisa Ovington at home at the request of her GP. Louisa Ovington talked about the problems with drinking and with her temper and explained that she did not mean the threats to Mr Hilton. CRT 1 concluded there was no role for the CRT - there were no signs of mental health problems - but she recommended anger management and said she would discuss the provision of mood stabilisers with Staff Grade Psychiatrist 1. 170. At this point there was still no allocated social worker. On 20 July 2004 the GP had rung social services to find out whether there was and been told there was not, because Louisa Ovington’s whereabouts were unknown. COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS This is surprising as the police, GP and staff at the CRT appear to have been in touch with her. 171. The disturbed behaviour continued. Police reports note: i. On 3 August 2004 Louisa Ovington was reported to have threatened a neighbour with a 7-8 inch kitchen knife. She is alleged to have been chatting to the neighbour when her mood suddenly changed; she picked up the knife and said “If I don’t murder you I will murder somebody just to get out of this shithole”; ii. On 4 August 2004 she reported being harassed by neighbours; iii. On 5 August 2004 she made five 999 calls while very drunk; iv. On the same day she was charged with criminal damage, assaulting a police officer and being drunk and disorderly; 61 v. On 11 August 2004 she committed an assault in a public house; vi. On 12 August 2004 Louisa Ovington was arrested for a public order offence. No further action was taken. She was taken to North Durham hospital A&E under the influence of alcohol but discharged herself; vii. On 13 August 2004 she was arrested for shoplifting; 62 viii. On the same day she smashed three windows in a house; 63 ix. On 20 August 2004 while in custody awaiting sentencing for various offences she was aggressive and threw urine over staff. 53
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 43 and 44: 129. Although Louisa Ovington conti
Page 51: there was “some latitude” in th
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 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
Page 103 and 104:
DS1 told the panel bluntly that, in
Page 105 and 106:
and social care agencies. The panel
Page 107 and 108:
CRO with a condition of psychiatric
Page 109 and 110:
COMMENT The probation officer estab
Page 111 and 112:
CHAPTER 5 - INVOLVEMENT WITH POLICE
Page 113 and 114:
COMMENT CHAPTER 5 - INVOLVEMENT WIT
Page 115 and 116:
CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 117 and 118:
CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 119 and 120:
• South West Durham Mental Health
Page 121 and 122:
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
Page 145 and 146:
f) Use of “talking therapies” C
Page 147 and 148:
professional who had seen her withi
Page 149 and 150:
i) Joint working CHAPTER 9 - CONCLU
Page 151 and 152:
their procedures for formal contact
Page 153 and 154:
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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