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

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CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF LOUISA OVINGTON 78 Addictions services The panel was informed that addiction services were mainly provided by three teams: ESMI (Easington Substance Misuse Initiative) which covered the Peterlee area; CAS (Community Addictions Service) which covered the Sedgefield District Council locality and NECA (the North East Council for Addictions). The first two services worked with clients on a practical and medical level to address their addictions, the third was a counselling service. Whilst there were addiction services in the area, the panel was told that they focussed mostly on opiate use and that alcohol services were more “thin on the ground”. Thus, alcohol treatment was largely left to the care of general mental health services. Louisa Ovington was apparently first seen by drug and alcohol services regarding her drug use when she was 15 or 16, although the panel has seen no contemporaneous records of this contact. She was referred to ESMI just prior to her first admission – but the panel again saw no records of this contact, if it did occur. The issue of Louisa Ovington’s substance misuse was not specifically addressed whilst she was at the Tony White Unit or at St Nicholas’ Hospital, although its contribution to her difficulties was noted. When she was at St Nicholas’ hospital she was assessed by a psychologist from the Newcastle forensic adolescent service who noted that drug use was an issue, but that although she might respond to relapse-prevention work she had at that time little motivation to change. It was suggested that a motivational interviewing approach regarding drugs might be useful. Psychologist 1 (psychologist at St Nicholas’) noted that Louisa Ovington related all her past difficulties to the abuse of illegal drugs. Consultant 10 (Psychiatrist from Rampton who assessed her at St Nicholas’) described Louisa Ovington as a complex and quite profoundly disturbed individual. He felt that she required a period of treatment in a controlled setting until that was a satisfactory understanding of her emotional insecurity and instability and until there was adequate support to ensure that she did not take drugs. Otherwise, he felt that the consequences could be serious or indeed grave. When Louisa Ovington moved on to Kneesworth House, she engaged in a psychology assessment process, but during this it was noted that although she clearly attributed all her difficulties to her substance misuse, she was “blithely convinced” she would have no difficulty avoiding drugs in the future. One to one psychology sessions and a drug and alcohol group were proposed to address Louisa Ovington’s lack of relapse prevention strategies regarding illicit substance use. An inexperienced psychologist attempted to work with Louisa Ovington on this, but Louisa Ovington was apparently resistant and guarded and she avoided effectively doing this work. She did, however,
take part in several sessions of a women’s substance misuse group. The assistant psychologist was planning to work on drug issues in future sessions after the Christmas break, but Louisa Ovington was discharged before this could take place. The psychology department final report dated 20 January 2000 noted that Louisa Ovington’s primary way of understanding all of her difficulties was “in terms of her drug use” – her coping strategy being to not use drugs again, as she had promised her uncle John before his death that she would give them up. The psychologists noted that external factors that appeared to have played a part in Louisa Ovington’s psychotic breakdowns included her drug use, relationship instability, a drug using peer culture and a lack of purpose and direction in her life. However, the overall conclusion appears to have been that Louisa Ovington was “not ready” to engage in a community based drugs rehabilitation programme. COMMENT CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF LOUISA OVINGTON The impact of drugs on Louisa Ovington’s mental health was clearly recognised by the staff at all three hospitals. Louisa Ovington was not willing to address this issue but attempts were made to work on it when she was at Kneesworth House. However, it was inappropriate to ask an unqualified, inexperienced, assistant psychologist to do this work with a reluctant, defended and resistant patient. Nonetheless, it does seem that Louisa Ovington did begin to engage with the process. Further work was planned, but this was prevented by her very abrupt discharge from hospital. Given that she was beginning to engage as an inpatient and the psychologists were clear that she was not ready to engage in a community based drugs rehabilitation programme, it appears very unfortunate that she was discharged at this point. The panel noted that professionals were only concerned about Louisa Ovington’s drug use at this time, not alcohol. This was understandable as, although alcohol contributed to the events that led up to Mr Hilton’s death Louisa Ovington did not apparently have a problem with alcohol in 1999 / 2000. At the CPA meeting held on 24 January 2000, following Louisa Ovington’s discharge from Kneesworth House, it was agreed that Louisa Ovington would be referred to the community drug and alcohol team “if she required further support”. Louisa Ovington did not wish to be referred to the drug and alcohol service at that time. Within six months, Louisa Ovington was using drugs again: she told Social Worker 4 on 14 June 2000 that she was thinking of coming off drugs. Two weeks later she agreed that he could refer her to the Community Addictions Service, (CAS), this being the addictions service for the Sedgefield locality. She was then using over £30 of heroin a week. Prior to her first appointment with CAS she told Social Worker 4 that 79
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REPORT TO THE NORTH EAST STRATEGIC
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Contents CONTENTS Page Preamble 6 I
Page 7 and 8:
Introduction and terms of reference
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The panel met on 14 occasions, tota
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CHAPTER 1 - NARRATIVE OF KEY DATES
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This opinion was referred to by man
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Page 17 and 18:
20 May 1998 to 12 January 1999 CHAP
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Page 21 and 22:
Page 23 and 24:
60. As was common in 1998, there we
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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 35 and 36: CHAPTER 1 - NARRATIVE OF KEY DATES
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 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: On 10 July 2001 Louisa Ovington att
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
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CHAPTER 8 - USE OF THE MENTAL HEALT
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CHAPTER 8 - USE OF THE MENTAL HEALT
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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
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • The pol
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Bibliography 1. Effective Care Coor
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INTRODUCTION 28 North East Strategi
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