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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 64 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.
210. CPN 2 also completed a risk assessment. This noted some risks, low to medium and particularly associated with alcohol, but did not appear to take account of the complexities and history of Louisa Ovington’s relationship with Mr Hilton. 211. On 22 November 2005 at court for the criminal damage Louisa Ovington’s existing two year order CRO was replaced by a twelve month CO with conditions 81 . 212. Louisa Ovington did not like the new probation officer and probation quite quickly recorded that because of her abusive and aggressive behaviour there were to be no home visits due to potential risk to staff. COMMENT CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS The panel was told that where circumstances change consideration should be given to reviewing an existing OASys assessment. The OASys assessment completed for the court hearing on 22 November 2005 had indicated that Louisa Ovington’s risk of harm to the public was medium - despite a very high OASys score. A short while later it was noted that probation had decided that Louisa Ovington was too risky to visit at home; no new OASys assessment was done at this time and this information was not shared. 213. CPN 2 visited Louisa Ovington on the 7 December 2005; she had ‘fallen out’ with Mr Hilton again and she expressed her dislike of the new probation officer. CPN 2 visited again on the 20 December and no problems were noted. Louisa Ovington had seen the social work assistant on the 14 December and commented both to the assistant and to CPN 2 that she was ‘fine’ about having fallen out with Mr Hilton. 214. On 2 January 2006 police records note that Louisa Ovington reported she had been assaulted by Mr Hilton. No action was taken. 215. On 4 January 2006 Louisa Ovington cancelled a planned visit by the social work assistant as she had flu. 216. On 8 January 2006 Louisa Ovington killed Mr Hilton by a single stab wound to the heart, with a kitchen knife, whilst he lay in bed at her accommodation. They had each been with other people during the day and had both consumed a very large amount of alcohol. There was no evidence that their sexual relationship had started again but according to the trial transcripts they had seen something of each other over the Christmas season. Louisa Ovington said that Mr Hilton was boasting of his conquests and she only intended to hurt his arm. Louisa Ovington pleaded not guilty to a charge of murder and after a trial was convicted of manslaughter and given an indeterminate sentence of imprisonment for public protection. 81 15th conviction 65
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 15 and 16: CHAPTER 1 - NARRATIVE OF KEY DATES
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 61 and 62: 78 21st offence 204. However Louisa
Page 63: hours. They did not have access to
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
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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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