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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 56 180. A pre-sentence report was prepared. The probation officer concluded that Louisa Ovington presented a high risk of harm to the public and a high risk of reoffending; commented that her behaviour was bizarre on interview and said she could not make recommendations without a psychiatric report. Her assessment (an OASys 64 ) suggested a MAPPA referral was indicated. This was not followed up. 181. On 10 September (without the benefit of a psychiatric report) the court sentenced Louisa Ovington to a two year CRO 65 . There was liaison between the remand centre, social services, the CRT and social services emergency duty team. The CRT tried to make contact with Louisa Ovington but failed. 182. The GP asked for advice about medication for Louisa Ovington on 20 September 2004. He had no response and prescribed an antipsychotic for one week. 183. Between September 2004 and November 2004 Louisa Ovington’s chaotic and disturbed behaviour continued to cause concern. Various records note the following (but in some cases it was not possible to establish details): i. On 20 September she made an allegation (with a 999 call) that a neighbour was firesetting (no evidence of this); ii. On 21 September she was arrested at a hotel for not attending court; iii. On 22 September she made an “abusive and agitated” call to her GP, who referred the matter to Staff Grade Psychiatrist 1 for urgent advice; iv. On the same day she made a “hysterical” 999 call claiming that Mr Hilton would not let her out of the house. She was taken under Section 136 MHA 66 to Hartlepool General Hospital. She had apparently self harmed but was assessed as no risk to herself and refused admission. Social Services tried to find her accommodation but were unable to do so. She had to be removed by police; v. Two days later she was convicted of criminal damage (committed on 17 July 2004); 67 vi. She found temporary hostel accommodation near Hartlepool but was threatened with eviction as she broke the rules about alcohol and at some point she was in fact evicted; vii. Despite the efforts of Social Worker 7 and Team Manager 2 she failed to attend an emergency outpatients appointment or a case conference ( see later), or indeed any outpatient appointments during this period; 64 Offender Assessment System ( a Probation Service risk assessment tool) 65 9th conviction 66 See Chapter 8 67 10th conviction
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS viii. When Social Worker 7 finally met her on 10 October 2004 she was “quite high and paranoid” and felt she was being stalked by Mr Hilton. She said that if she saw him she would be driven to attack him. She was apparently taking antipsychotic medication bought off the street; ix. On 20 October 2004 she was charged with breach of the peace while drunk; 68 x. On 5 November 2004 she was charged with criminal damage having used a knife to scratch a car. 69 On the same day she was charged with being drunk and disorderly and damage to a police cell; 70 xi. On 9 November 2004 Louisa Ovington was in custody again, having broken a curfew; xii. On the same day she was convicted for the offences of 5 November 2004; 71 xiii. On 20 November 2004 she was charged with being drunk and disorderly and threatening behaviour ( threats to stab); 72 xiv. She was evicted from her (temporary) accommodation at some point; xv. Louisa Ovington was convicted of the drunk and disorderly offence of 20 November 2004 and received a conditional discharge; 73 xvi. At some point she was remanded in custody again and remained in custody until 14 January 2005. Between June 2004 and November 2004 Louisa Ovington had committed 11 sets of offences and in addition had been arrested for being drunk and disorderly or for public order offences (which were not proceeded with). Several of the offences for which she was charged involved violence. In relation to these offences she received eight convictions between June 2004 and January 2005. 184. From 9 September 2004 Louisa Ovington was subject to a two year CRO. She was under the supervision of Durham Probation Service. At various points it was noted that she was supposed to be completing a citizenship programme involving work on anger management and alcohol abuse control. Louisa Ovington was moving around and it was unclear which probation office should remain responsible for her; it appears that Hartlepool took over a ‘caretaking’ role for a few months and then the responsibility was transferred to them. The records show that Social Worker 7 kept in touch with probation as far as she was able. 68 17th offence 72 20th offence 69 18th offence 70 19th offence 71 11th conviction 73 12th conviction 57
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 and 52: there was “some latitude” in th
Page 53 and 54: 61 14th offence 62 15th offence 63
Page 55: 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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