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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
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185. Following the brief visit to Hartlepool General Hospital on 22 September 2004,
(see paragraph 183 (iv)) Louisa Ovington was referred to the CRT, but they were
unable to track her down. Team Manager 2 from the CRT was very concerned about
Louisa Ovington. He wrote to Social Worker 7 to express his concern that Louisa
Ovington was continuing to come into contact with the criminal justice system and
that there was ‘still a lack of clarity around the mental health service response’ adding
that ‘ the need to develop a joint management plan is pressing’.
186. In the meantime, the GP was concerned about Louisa Ovington’s presentation
and had been trying to get advice about prescribing medication for her from
Consultant 13. He (Consultant 13) arranged for her to see Staff Grade Psychiatrist 1
urgently in Outpatients on 30 September 2004 and advised on medication.
187. Team Manager 2 attended the outpatients appointment on 30 September 2004
but Louisa Ovington did not attend. She had missed a probation appointment as well.
188. Team Manager 2 had in August asked Staff Grade Psychiatrist 1 to arrange a
case conference. This took place on 5 October 2004. By then it was known that Louisa
Ovington was living in homeless accommodation in Hartlepool, but that she would be
evicted within ten days as she had broken rules by drinking. A representative attended
from the CRT, as well as Social Worker 7, Staff Grade Psychiatrist 1 and Probation
Officer 4. The police were not in attendance. Although there were concerns expressed
about the impossibility of formulating a management plan for Louisa Ovington, until
she “engages with services and has a firm address”, Social Worker 7 stressed the need
to keep communication open; she also expressed her view that a ‘public protection
meeting should be called to include the police, given Louisa Ovington’s potential risk
to herself and others’.
189. An outpatient appointment was arranged on 7 October and it was agreed that if
she failed to attend appropriate action would be taken and relevant people would be
informed. It was also agreed that there should be a forensic assessment.
190. Louisa Ovington did not attend the outpatient appointment despite Social
Worker 7 letting her know it had been put back for two hours to accommodate her;
Social Worker 7 did attend. Staff Grade Psychiatrist 1 proposed to discharge Louisa
Ovington from services since she had failed to attend two appointments. At the
appointment Social Worker 7 again suggested to Staff Grade Psychiatrist 1 that it
might be helpful to refer Louisa Ovington to forensic services and that Louisa Ovington
might benefit from DBT 74
74 Dialectical behaviour therapy- a specific psychological therapy for the treatment of emotionally unstable personality disorder.