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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
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172. As a result of the incident on 3 August 2004 Durham Constabulary sent an adult
concern form to Durham social services. There was still no allocated social worker. The
head of the CRT, Team Manager 2, was sufficiently concerned to press Staff Grade
Psychiatrist 1 to organise a case conference involving the police and other relevant
parties, to create a joint management plan.
173. On 16 August 2004 an agency social worker, Social Worker 7, was allocated
from the CMHT.
COMMENT
February 2004 when Louisa Ovington apparently agreed that she did not need social
services input and Social Worker 5 closed the file to social services, marked the start of
a period of extreme turbulence in Louisa Ovington’s life, in which the services offered
appeared to be more in the nature of ‘fire fighting’ than resulting from planning
and discussion about her needs. Although Louisa Ovington remained subject to CPA/
Section 117 there is no evidence that Consultant 2 acted on the letter written to him
by Social Worker 5 informing him that he was now the care coordinator: it appears
from the CPA records that Staff Grade Psychiatrist 1 was officially the care coordinator
from March 2002 (although Staff Grade Psychiatrist 1 told the panel that he had not
joined the trust until 2003). Thus, she was effectively left without a care coordinator
until the appointment of Social Worker 7 in August 2004.
174. It seems that over the summer of 2004 mental health services failed to accept
their responsibility for the care of Louisa Ovington. Her behaviour was extremely
disturbed and Louisa Ovington herself acknowledged that she was “out of control”.
From the records, it appeared to the panel that Staff Grade Psychiatrist 1 accepted
that Louisa Ovington had been diagnosed with a severe personality disorder with
a primary diagnosis of alcohol dependency. On the basis of this he and the CRT
considered that she ‘did not experience mental health problems’ and that there was
therefore no role at that time for the CRT. Staff Grade Psychiatrist 1 confirmed to the
panel that he did not think that Louisa Ovington was suffering from a mental illness
and he said that he saw no evidence of depression, psychosis or cognitive impairment.
Even if it is accepted that Louisa Ovington was not suffering from a mental illness
(such as schizophrenia or bipolar disorder), her mental state was disordered and
chaotic at this time and it was causing problems to her and to others.
175. Whilst it would not have been appropriate for the CRT to take on a care
coordination role, they did work with patients for up to six weeks at a time. It might
have been helpful had they done this with Louisa Ovington.