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

The essence of CPA is to ensure care coordination, which put simply, should prevent
those with greatest need from falling through the net of available services. This is
particularly important where geography is an issue or in major cities where services
can often be fragmented across boroughs or districts. When someone who has a
mental illness that requires enhanced levels of care chooses to move localities, this can
present major problems for service providers and in the case of Louisa Ovington this
presented a significant challenge.
The role of care coordinator was created to ensure that a professional with appropriate
knowledge and skills maintained oversight of those under their care. This is not to
say that the care coordinator must be involved in all aspects of care, but that he or
she should have an ongoing awareness of who is doing what to whom where and
that those who are involved in the care are appropriately informed, including of
course the service user and their carers. This should be implemented through the
establishment of regular CPA meetings where care is planned and reviewed and the
distribution of care plans through written or electronic means. Due to the complexities
of coordination and the time involved it is expected that those on enhanced CPA will
not be care coordinated by medical staff, (but this is an option for those on standard
CPA whose needs are less).
This role is assisted in each mental health trust by the provision of a CPA department,
headed by a manager who should ensure that CPA is properly functioning, staff are
appropriately trained, policies and updated guidance are available, regular audit is
undertaken and care plans are regularly reviewed.
COMMENT
CHAPTER 4 – THE CARE PROGRAMME APPROACH (CPA)
It is clear from the evidence received by the panel that Louisa Ovington’s movements
since she first came into contact with the mental health services have presented a
challenge to the staff responsible for providing her care. This challenge has been made
more difficult as a result of the major organisational changes resulting from national
policy guidance and local mergers of mental health services and has placed a greater
responsibility on local managers and practitioners to ensure smooth transition and
continuity of care.
It is also clear from the evidence that this worked well on occasions but on others
it left much to be desired. The movement of Louisa Ovington between localities
and teams was not well coordinated and where robust care plans and transfer
documentation should have been in place, there was in fact little evidence of this.
This was clearly illustrated in the poor discharge planning arrangements when Louisa
Ovington was at Kneesworth House and later on, the relatively poor joint working
and communication between the CRT and the CMHT. Similarly, it was recognised
that Louisa Ovington was a challenge to the specialist teams and her level of
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