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

CHAPTER 2 – EVALUATION OF THE HEALTH CARE AND TREATMENT OF
LOUISA OVINGTON
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her, because she had never had a response to the letters she sent Louisa Ovington in
March 2004. Louisa Ovington’s GP was concerned that Louisa Ovington had been
discharged by CAS 2 and wrote to her, asking her to reconsider it. However, by
this time CAS 2 had left the service. Following her discharge from hospital, Louisa
Ovington attended at a CPA meeting during which she stated that alcohol was her
main problem, that she had problems with her temper which she was unable to
control and that she got aggressive at times towards her partner. It was agreed at the
CPA meeting that she needed education regarding substance misuse, which should be
provided by staff from ESMI. This did not happen.
COMMENT
During these three years, Louisa Ovington continued to only briefly acknowledge
having any difficulties. However, it is evident that her alcohol consumption was already
associated with aggressive behaviour and that it was exacerbating the difficulties in
her relationship with Mr Hilton.
Whilst CAS 2 did complete a very brief risk assessment, it appeared to the panel that
she was not engaged with the CPA process and she acknowledged to the panel she
had no contact at all with Louisa Ovington’s care coordinator. She said that her remit
working with ESMI was just to look at the drug and alcohol problems. Like CAS 1 she
said that staff would have assumed that the issues to do with Louisa Ovington’s past
would have been dealt with by others. This appears to be an issue either of poor care
coordination, in that the different professionals working with Louisa Ovington did
not know what each other was doing, or of there being too many separate specialist
services (counselling for addictions being done separately with NECA from both ESMI
and CAS).
CAS 2 told the panel that the role of ESMI was to try to engage patients within their
service and to manage reduction or abstinence programmes. As she said, however,
they did not try to “force programmes” onto people, so if patients did not keep
appointments it would be assumed that at that point in life that person didn’t want
to go further forward regarding the programme. However, the “door would be left
open for patients to return in the future if they so wished. But in this particular case
more assertive attempts at engagement by staff would have been helpful given Louisa
Ovington’s longstanding reluctance to be involved with services and the previous
assessments that had identified the role of drug use in her mental health difficulties.
Louisa Ovington had no further input from specific addiction services after May 2004.
However, it seems that there was some reluctance from other mental health services
to be involved with her because they considered her primary diagnosis to be that of
alcohol dependency. Staff Grade Psychiatrist 1 apparently told CRT 1 from the CRT