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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 60 196. On 20 January 2005 a probation assessment form (OASys) was completed that indicated that Louisa Ovington was low risk and there was no need for a referral to MAPPA. 197. On 4 February 2005 Louisa Ovington received her fourteenth conviction for offences committed the previous August and was given a conditional discharge and compensation order 77 . 198. Social Worker 7 went to some lengths to try to get Louisa Ovington housed. At this time probation recorded that she was talking about becoming engaged to be married to Mr Hilton. 199. On 22 March 2005 Louisa Ovington attended an outpatient’s appointment with Staff Grade Psychiatrist 1 (accompanied by Social Worker 7). It was the first time in nearly a year that she had seen him. She reported that she had ‘been off’ alcohol for nearly four months (of which she had been in prison for nearly two) and that this (alcohol) was her ‘big problem’. She was to continue on anti psychotic medication and a mood stabiliser. 200. The care coordinator, Social Worker 7, prepared a quite detailed care plan, jointly agreed with Staff Grade Psychiatrist 1 and Louisa Ovington. She was on enhanced CPA. Her stated needs were housing, structured activities, completion of the 24 month CRO (which involved a citizenship programme covering anger management and alcohol abuse awareness overseen by a probation officer). In addition Social Worker 7 completed a Durham County Council social care and health practitioner progress chart. 201. In March 2005 Louisa Ovington moved to permanent supported accommodation. Social Worker 7 liaised with all parties to give full information about her situation. For the next four months Social Worker 7 worked hard to coordinate support for Louisa Ovington including sorting out her benefits and helping her consider further education possibilities. She instigated a referral to an education centre 202. In July Louisa Ovington saw Staff Grade Psychiatrist 1 and reported that she was well; no evidence of mental illness was noted. She had discontinued taking the antipsychotic medication. 203. In July 2005 Louisa Ovington’s CRO was transferred to the Hartlepool service 77 14th conviction
78 21st offence 204. However Louisa Ovington’s enthusiasm both for her housing and for education waned; she wanted to be nearer to Mr Hilton and on 30 July 2005 after a window was put out at her flat she went to stay with him. In September she moved to her own accommodation near him. Social Worker 7 reported that Louisa Ovington was “desperate to be near” Mr Hilton. The move, away from supported accommodation, caused some problems with Louisa Ovington’s benefits which Social Worker 7 was involved in sorting out. 205. In early October 2005 there were signs that Louisa Ovington’s mental state was deteriorating: • She attended A&E at Hartlepool General Hospital after telling her GP that she had taken an overdose of her mood stabilising medication and eight cans of lager. The hospital diagnosed alcohol poisoning and discharged her after giving her advice; • She caused criminal damage to Mr Hilton’s property on 8 October 2005, for which she was arrested and charged; 78 • She reported that Mr Hilton was drinking again. 206. Her mood was noted by Social Worker 7 to be low and she took immediate steps to assist and support her, involving a representative from ‘Mental Health Matters’, a mental health charity offering services and support in the region. It was arranged that she would look again at the possibility of a college course, might consider voluntary work and would have some help with structuring her day. A CPA meeting was to be organised for 27 October 2005. Louisa Ovington agreed to contact her GP and was prescribed an anti-depressant. 207. Social Worker 7 visited Louisa Ovington on 26 October 2005 to tell her she was leaving but that she would continue to be supported. A CPA meeting was to take place the following day. The new care coordinator was to be CPN 2. Staff Grade Psychiatrist 1 would attend, Louisa Ovington would be provided with outreach support by a worker (Support Worker 1) and a CPN (CPN 1) would give an overview. Mental Health Matters would support her. COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS The panel could not trace the record of the meeting. It seems that Social Worker 7 may have left somewhat abruptly because she was an agency social worker. 61
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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 and 56: 176. Social Service staff did respo
Page 59: CHAPTER 1 - NARRATIVE OF KEY DATES
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
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CHAPTER 5 - INVOLVEMENT WITH POLICE
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COMMENT CHAPTER 5 - INVOLVEMENT WIT
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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• South West Durham Mental Health
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CHAPTER 7 - PROVISION OF MENTAL HEA
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The policy changes were driven by t
Page 125 and 126:
• Past psychiatric history; • S
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CHAPTER 8 - USE OF THE MENTAL HEALT
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Page 131 and 132:
Page 133 and 134:
Given the multiplicity of agencies
Page 135 and 136:
CHAPTER 9 - CONCLUSIONS AND RECOMME
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Page 139 and 140:
Some of the risk assessments from a
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• Recommendation 16. Trusts shoul
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f) Use of “talking therapies” C
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professional who had seen her withi
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i) Joint working CHAPTER 9 - CONCLU
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their procedures for formal contact
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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
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INTRODUCTION 28 North East Strategi
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