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

CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF
LOUISA OVINGTON
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she had “kicked the habit”. She failed to keep the first couple of appointments with
CAS, but was finally seen in October 2000.
COMMENT
CAS 1 told the panel that CAS would attempt to engage with patients by sending out
letters to them offering them further appointments if they failed to attend. However,
if the patient failed to attend twice and did not respond to the letters, then they
would be discharged. The “door” would be left open for them to re-refer themselves
to CAS if they so wished.
CAS 1 set up a community based heroin withdrawal programme for Louisa Ovington.
She also referred her to Orbit 20, a community support agency. Whilst she did not
meet up with Social Worker 4, she did communicate with him by telephone and when
she had concerns regarding Louisa Ovington’s mental state she alerted him to this,
suggesting for example that it might be helpful for a CPN to be involved. She saw
her role as that of a nurse purely treating drug addiction. She told the panel that she
assumed that Louisa Ovington was working on her early life experiences with other
people, such as her care coordinator, Social Worker 4.
COMMENT
CAS 1 told the panel that CAS did not follow the CPA, or carry out formal risk
assessments, at this time. Nonetheless, she appears to have worked reasonably closely
with Social Worker 4. She was invited to attend a CPA meeting in January 2001, but
she was unable to attend this and the meeting was cancelled. The panel recognises
that it can be difficult to arrange CPA meetings involving professionals from different
agencies, but such meetings are important particularly when numerous agencies are
involved and when professionals are assuming very demarcated roles.
Louisa Ovington was supported by workers from CAS until February 2001. At this
point, she had apparently been drug free for two months and urinalysis was negative
for opiates. However, excessive alcohol consumption was becoming a problem; at the
New Year she had been remanded in custody by the police after “running around with
a knife” under the influence of alcohol. Furthermore, she told Social Worker 4 on 24
January 2001 that she was using alcohol as a substitute for drugs. Nonetheless, CAS
1 felt that Louisa Ovington was aware of the risks of excessive use of alcohol and she
discharged her from CAS on 7 February 2001.