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

CHAPTER 4 – THE CARE PROGRAMME APPROACH (CPA)
was held on 5 December 2000 to coordinate her care package. At this time Louisa
Ovington was also being seen by the community addictions team. She told her
care coordinator that she was unhappy with her housing, confused regarding her
feelings about her father and that her relationship with her boyfriend appeared to be
deteriorating.
Social Worker 4 arranged a CPA meeting on 8 January 2001 but it did not take place
as neither the GP nor the community addictions worker could attend. However, he
met with Louisa Ovington the following day and a care plan appropriate for her needs
was drawn up.
On 1 February 2001 Louisa Ovington was admitted to Darlington Memorial Hospital
following an attempt at cutting her wrists. She was discharged on 5 February and
a CPA/Section 117 document was completed on 6 February 2001. Consultant 15
completed a risk assessment document on 8 February 2001 and probation, as part
of a pre-sentence report in connection with an offence of possession of an offensive
weapon, also completed one on 11 February 2001 which noted a high risk of
dangerousness and reoffending.
Social Worker 4 continued to follow her up and noted that she had replaced drugs
with alcohol consumption. Louisa Ovington agreed to a request from Social Worker 4
that she be referred to a psychiatrist. (It seems surprising that she had not continued
with support from a psychiatrist after discharge from Darlington Memorial Hospital.)
On 14 February 2001, Social Worker 4 received the discharge summary from
Darlington Memorial Hospital which recommended that Louisa Ovington should be
referred to community psychiatric nurses. Social Worker 4 agreed to pursue this. At
the beginning of March 2001 Louisa Ovington registered with a new GP.
On 10 April 2001 Social Worker 4 wrote to the GP requesting that Louisa Ovington
be referred to psychological services. He responded by referring Louisa Ovington to
Consultant 15 instead of psychological services.
During 2001 Louisa Ovington had a great deal of involvement with the criminal justice
system, but not apparently with health/social care. Her care coordinator however was
concerned about her deteriorating mental health and arranged a CPA meeting in July.
He felt that Louisa Ovington needed urgent psychiatric treatment. At this point Social
Worker 4 was informed that Consultant 5 would be the psychiatrist with responsibility
for Louisa Ovington. On 2 August 2001 her GP received a letter from on behalf of
Consultant 15 discharging Louisa Ovington from his care.
During October 2001 there was confusion about the identity of Louisa Ovington’s
consultant. She was seeing Consultant 5 at Darlington Memorial Hospital, but also
apparently Consultant 14 at Peterlee health centre. Louisa Ovington was also referred
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