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

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
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