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

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CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF LOUISA OVINGTON 68 She was appropriately medicated. The second and third admissions were much shorter, the second lasting less than a month and the third just one day. As before, she was appropriately assessed and treated during admission number two. Nonetheless, during the course of this admission Louisa Ovington allegedly became involved in a relationship with a male member of the nursing staff, who was subsequently disciplined and dismissed. This highlighted to the panel the difficulties in caring for Louisa Ovington. Louisa Ovington’s discharge from her second admission to hospital was precipitated by her using illicit substances during a period of leave. Her third admission was ended within a day of her arrival on the ward, after she used illicit drugs on the ward. It is relatively common practice for patients to be immediately discharged from hospital if they bring in, or use, such substances, provided it is safe to do so. Louisa Ovington was appropriately followed up on each occasion that she was discharged, by a community psychiatric nurse and in outpatients. She was also prescribed ongoing treatment with antipsychotic medication. Louisa Ovington’s fourth admission, for ten days in May 1997, was to the Royal Edinburgh Hospital. The Hartlepool services made some effort to ensure that the team in Edinburgh were informed about Louisa Ovington. Again, she was appropriately assessed and treated whilst in hospital. Her diagnosis was, rightly, reviewed – the comment being made that it was “more likely one of schizophrenia than of drug induced psychosis”. On her discharge, arrangements were made for her to be reviewed in outpatients, even though Louisa Ovington was not certain whether she would be remaining in the area. Louisa Ovington returned to the Hartlepool area and was followed up in outpatients. Consultant 6 tried to support her in the community, for example assisting her return to college. In May 1998 Louisa Ovington committed several offences and was remanded in custody. She was noted to be severely psychologically and behaviourally disturbed. She was assessed appropriately by Consultant 8 who, when she did not respond to the medication he prescribed, correctly arranged for her transfer to hospital, under Section 35 of the Mental Health Act, which allows for assessment in hospital 82 . Louisa Ovington spent the next eighteen months detained in hospital, first at Durham County Hospital, then at St Nicholas’ Hospital, then at Kneesworth House. The panel was unable to clarify why Louisa Ovington was admitted to Durham County Hospital instead of the local forensic unit, St Luke’s Hospital in Middlesbrough. It was 82 See Chapter 8
CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF LOUISA OVINGTON unfortunate, however, that rather than suffering from what would might have been a relatively short lived episode of psychosis, Louisa Ovington’s difficulties proved be more long lasting and the role of the PICU became one more of containment, rather than treatment, until she could be transferred to a more appropriate setting. Nonetheless, during this admission Louisa Ovington underwent numerous physical and psychiatric assessments and her psychotic symptoms were appropriately treated with trials of different psychotropic medications. At Durham County Hospital, Louisa Ovington verbally and physically assaulted staff and other patients on numerous occasions. The attempt by staff to manage this by using behavioural techniques was appropriate, but in the panel’s view the police should have been asked much earlier on to charge Louisa Ovington for her offences. The work carried out at St Nicholas’ Hospital confirmed Louisa Ovington’s diagnosis of a personality disorder, but again she was felt to be inappropriately placed there for treatment. Consequently, the focus of attention again became that of finding an alternative setting for her. However, the clinical team used the time to collate a very thorough resume of Louisa Ovington’s past psychiatric contacts. Whilst at Kneesworth House Louisa Ovington underwent a thorough medical assessment. The majority of the work however was psychological. The attempt to assess whether she had a mood disorder underpinning her psychosis and aggressive behaviour was appropriate, however, a month medication free was an insufficient time period to determine this. A CPA meeting was held 12 days after Louisa Ovington’s discharge from Kneesworth House. She was allocated a social worker as her key worker. It was agreed that she would be seen by addictions services and CPNs in the future if she so wished and it was deemed appropriate. Given Louisa Ovington’s failure to engage with such services whilst an inpatient, the panel felt that this plan was at very least overly optimistic. During the first four months following her discharge, Louisa Ovington was not in fact seen by any mental health professionals. Thereafter, she was followed up by a series of care coordinators and she was intermittently seen in outpatients by doctors (most of whom were locums from whom she received little continuity of care). She had a brief admission in February 2001 to Darlington Memorial Hospital. Whilst technically this admission lasted five days, she went on leave the day following her admission and failed to return. Consequently, no useful work was carried out during this admission. It appears that a diagnosis of bipolar affective disorder was considered at this time and there were plans to commence her on a mood stabilising medication, but she left the hospital before this was done. She had a further brief admission in May 69
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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 15 and 16:
CHAPTER 1 - NARRATIVE OF KEY DATES
Page 17 and 18: 20 May 1998 to 12 January 1999 CHAP
Page 19 and 20: CHAPTER 1 - NARRATIVE OF KEY DATES
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 and 64: hours. They did not have access to
Page 65 and 66: 210. CPN 2 also completed a risk as
Page 67: 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
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CHAPTER 7 - PROVISION OF MENTAL HEA
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The policy changes were driven by t
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• 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
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CHAPTER 9 - CONCLUSIONS AND RECOMME
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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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