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

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INTRODUCTION AND TERMS OF REFERENCE 8 Provision of evidence Between 1993 and January 2006 Louisa Ovington was involved with psychiatric services as an inpatient and an outpatient at seven different hospitals. She was also involved with community mental health services throughout the region. The panel had access, with Louisa Ovington’s consent, to all known documentation detailing her involvement with health, police, social services and probation other than her education records and children’s social services records (which may have been destroyed). All the agencies were helpful and cooperative in producing records and also in assisting the panel with details of policy and procedure documents and copies of protocols. The documentation was vast and amounted to in excess of 6,500 pages. Louisa Ovington was, over the years, involved with ten different trust areas, primarily those which now comprise the Tees Esk and Wear Valleys NHS Foundation Trust (TEWV), as well as Newcastle, Durham and Edinburgh and an independent sector hospital, Kneesworth House, in Hertfordshire. Because Louisa Ovington was involved with so many different trusts, because she moved around a great deal and because of many organisational changes, it proved complicated to establish who had clinical/CPA oversight of her at any one time. The police authority with whom she was involved was at all times Durham Constabulary. The probation services were provided mainly by Durham Probation Service with a short involvement by Teesside Probation Service. The panel had access to the Tees Esk and Wear Valleys NHS Foundation Trust’s internal investigation report dated February 2008 as well as the police Domestic Homicide Review 1 . This included part of the trust’s internal investigation report and the internal review reports of Durham Probation Service and County Durham Social Services. Sadly, Louisa Ovington consistently declined to meet the panel or have any contact, direct or indirect, with them. Although the panel has striven to ensure that what is reported here is factually correct, it has not been possible to check those facts with her. The panel was, however, assisted by an opportunity to visit the prison where Louisa Ovington is currently detained and where she was a participant in the Primrose Project, a government pilot programme dealing with dangerous and severe personality disordered offenders and by a discussion (which took place with her consent) with the team of clinicians involved in her care there. 1 See Chapter 5
The panel met on 14 occasions, totalling 34 days. The panel interviewed 21 witnesses whose names have been withheld in this report. They and the others who were involved in Louisa Ovington’s care are referred to by their professional titles and numbered, e.g. Psychiatrist 1. The names have been made available to the SHA. The witnesses’ evidence was transcribed and then checked by each witness for factual accuracy. Despite the coordinator’s strenuous efforts it was impossible to contact some of the witnesses whom the panel wished to interview and therefore conclusions about their work with Louisa Ovington had to be drawn from other evidence. The panel fully recognised the difficulty faced by witnesses who, in some cases, were being asked to recall events in which they were involved up to 11 years ago. The panel is very grateful to all the witnesses for their admirable efforts to ‘flesh out’ the paper records. The panel was grateful to: INTRODUCTION AND TERMS OF REFERENCE • Dr E Gilvarry, Consultant Psychiatrist, Northern Regional Drug and Alcohol Services, Newcastle upon Tyne • Ms M Trendell, Professional Head of Social Work, Sussex Partnership NHS Foundation Trust, trainer in MAPPA issues for the Mental Health Tribunal • Mr Jeff McCartney, former Assistant Chief Officer, Northumbria Probation Service with lead responsibility for public protection and offender management in Tyne and Wear for their expert and illuminating explanation and commentary on, respectively: • the provision of addiction services generally; insight into the type of problems with which clients may present and services offered; • The provisions of MAPPA (Multi Agency Public Protection Arrangements) 2 ; • The workings of the probation service, its functions and responsibilities. Some of the information about Louisa Ovington’s early life comes from accounts given to health and other professionals by her great aunt and uncle, who brought her up after the death of her mother. The panel of course fully recognises that it alone had the benefit of a perspective which was not limited to a snapshot of events but has been informed by a vast amount of information from different agencies - something which no other single agency had at the time. 2 See Chapter 5 9
Page 1: REPORT TO THE NORTH EAST STRATEGIC
Page 5 and 6: Contents CONTENTS Page Preamble 6 I
Page 7: Introduction and terms of reference
Page 11 and 12: CHAPTER 1 - NARRATIVE OF KEY DATES
Page 13 and 14: This opinion was referred to by man
Page 17 and 18: 20 May 1998 to 12 January 1999 CHAP
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
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CHAPTER 1 - NARRATIVE OF KEY DATES
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78 21st offence 204. However Louisa
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hours. They did not have access to
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210. CPN 2 also completed a risk as
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Chapter 2 - Evaluation of the healt
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CHAPTER 2 - EVALUATION OF THE HEALT
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During Louisa Ovington’s first ad
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Kneesworth House Louisa Ovington co
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The conclusion drawn by the psychol
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On 10 July 2001 Louisa Ovington att
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take part in several sessions of a
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COMMENT CHAPTER 2 - EVALUATION OF T
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CHAPTER 2 - EVALUATION OF THE HEALT
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
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CHAPTER 4 - THE CARE PROGRAMME APPR
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The essence of CPA is to ensure car
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Chapter 5 - Involvement with police
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89 ibid The guidance states that th
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DS1 told the panel bluntly that, in
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and social care agencies. The panel
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CRO with a condition of psychiatric
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COMMENT The probation officer estab
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CHAPTER 5 - INVOLVEMENT WITH POLICE
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COMMENT CHAPTER 5 - INVOLVEMENT WIT
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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CHAPTER 6 - RISK ASSESSMENT AND MAN
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• 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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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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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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