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

CHAPTER 4 – THE CARE PROGRAMME APPROACH (CPA)
time, drew up a CPA document which outlined the need to monitor her mental health
and educate her about substance misuse. It also recorded that Easington CRT should
be involved. Louisa Ovington remained on the ward until 15 May 2004 during which
time she had alcohol detoxication and was interviewed regarding an alleged rape.
Following a particularly tumultuous few months, Team Manager 2, CRT manager,
wrote on 9 August 2004, to Staff Grade Psychiatrist 1 asking for a case conference
involving the police and all relevant parties so as to create a joint management plan.
This did not happen.
On 16 August 2004 Team Manager 3, of the CMHT passed the case to Social Worker
7, who then became Louisa Ovington’s care coordinator.
On 22 September 2004 Team Manager 2 wrote to Social Worker 7 to reiterate the
need to develop a joint management plan in relation to Louisa Ovington’s continued
contacts with the criminal justice system and to say he hoped this would be agreed
and clearly recorded at the CPA meeting that he understood had been arranged for
5 October 2004. The meeting subsequently took place on 5 October 2004 and it
was recognised that there was a major issue with Louisa Ovington’s disengagement
with services. It was recorded that “it would be impossible to prepare a management
plan for Louisa Ovington unless she engages with the services and has a firm address
in the Easington District”. Social Worker 7, her Care Coordinator stressed that
“communication lines must be kept open and consideration needs to be given to
whether a public protection meeting should be called, which would include the police,
given Louisa Ovington‘s potential risk to herself and others.” It was also agreed at this
meeting to refer Louisa Ovington to forensic services but this was never done.
Social Worker 7 discussed Louisa Ovington at the team meeting on 12 October
2004 and as she (Louisa Ovington) had just transferred from Peterlee to Hartlepool
Probation Service, Social Worker 7 took the opportunity of raising the issue of a public
protection meeting. Probation responded that they did not think a public protection
meeting was necessary and recommended a multi-agency meeting instead.
On 2 November 2004 Louisa Ovington failed to attend a meeting with Staff Grade
Psychiatrist 1. He requested that the team consider whether she should be discharged
from services due to lack of engagement. On 23 November 2004 he wrote to Louisa
Ovington’s GP stating that he had offered Louisa Ovington three appointments which
she failed to keep and it was decided in the community team meeting that she be
discharged from their care.
Social Worker 7 completed a progress assessment on 1 January 2005 and noted that
Louisa Ovington was a “vulnerable young woman who when she drinks can be quite
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