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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
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208. During this period Louisa Ovington was reported to be worried about her
impending court appearance for the criminal damage committed on 8 October 2005.
Social Worker 7 contacted probation at the court to try to ensure there would be a
pre-sentence report (PSR) if she were not to receive a conditional discharge. A PSR
was prepared by Probation Officer 5 which assessed Louisa Ovington’s risk to the
public as medium (despite a very high OASys analysis). She supported the imposition
of Community Order (CO) 79 with conditions of supervision, to oblige Louisa Ovington
to complete a citizenship module and liaise with CMHTs and ESMI.
COMMENT
Care coordination
From March 2004, after discharge by Social Worker 5, Louisa Ovington’s behaviour
and presentation became more and more turbulent and disturbed. Social Worker
7, a mental health social worker with the CMHT, took over Louisa Ovington’s case in
August after six months without a CMHT worker. There is evidence thereafter that
considerable attempts were made by her to properly coordinate Louisa Ovington’s
care; she kept in close touch with probation, with the CRT and with the medical
services; she made contact with the Cleveland Court diversion team; she made
efforts to sort out Louisa Ovington’s housing situation and to support her in relation to
the consequences of her offending behaviour, as well as in relation to her engagement
with the psychiatric services. Additionally there is evidence that she became very
aware of the risks Louisa Ovington posed; she proposed referrals to forensic services,
to the personality disorder services and to MAPPA. None of these was acted upon.
Crisis Resolution Team
At points during this period, the CRT was also involved and there was evidence that
they responded to the requests to be involved, (although there was some confusion
about the referral in relation to the incident in June 2004).
CRT 1 told the panel that the service existed to offer intensive time limited support at
home to those suffering from severe mental health problems, with the aim of avoiding
hospital admission. However, she told the panel that the team tended to see more of
the “worried well” and people suffering from “social stresses”. She commented that
some GPs would say that patients were suicidal, (even if they were not) and that they
were not under the influence of drugs and alcohol (even if they were) to ensure that
the CRT would take them on. Nonetheless, CRT 1 also told the panel that she thought
it was appropriate of Staff Grade Psychiatrist 1 to refer Louisa Ovington to the team
when he did, because Louisa Ovington was in crisis at those times. She told the panel
that the crisis resolution service had very limited information about the patients with
whom they worked, particularly if they were referred them out of normal working
79 Community Orders replaced Community Rehabilitation Orders;