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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
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Manager 1 expressed surprise to the panel about the probation officers’ response to
Social Worker 7’s concerns; she suggested that Social Worker 7 could in any event
have made the referral herself - however she accepted the panel’s view that if Social
Worker 7 had specifically raised the issue of MAPPA with probation it would be
reasonable for her to accept their opinion.
Forensic
A referral to forensic services was apparently agreed in the meeting dated 5 October
2004 but never proceeded with. There were community forensic services in place
at the time, available for the Durham CMHTs to refer to and Louisa Ovington would
have fitted their criteria; they could have assessed her and the panel was told by
the consultant in charge of that service that they had better staffing levels than the
CMHTs and would have worked intensively with her. Staff Grade Psychiatrist 1 did
not refer to them; he told the panel he thought that she did not fit the criteria for a
forensic referral in October 2004, but that later on she should definitely have been
referred and that this should or would have been done by the care coordinator Social
Worker 7. The panel is surprised that given the incidence of disturbed behaviour and
increasingly frequent contacts with the police from June 2004, Staff Grade Psychiatrist
1 did not take personal responsibility for ensuring the referral after he had discussed
the matter with Social Worker 7 in early October 2004.
Custody diversion
Given the amount of contact Louisa Ovington had with the criminal justice system
in this period in particular the panel is somewhat surprised that there was so little
involvement of ‘custody diversion’ schemes, which were set up to divert people from
the criminal justice system into health care and to work alongside generic CMHTs in
respect of offending behaviour. However, in Louisa Ovington’s case, it may be that
such a scheme would not have been as effective as a forensic referral.
November 2005 to January 2006
209. CPN 2 formulated a care plan with Louisa Ovington, which placed her on
enhanced CPA and set out the agreed needs as: regular monitoring of mental
health through outpatients and home visits from CPN 2; assistance with housing and
finances; assistance with meaningful activities; reduction of aggressive behaviour and
completion of citizenship programme with probation, including alcohol awareness and
anger management.