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

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CHAPTER 4 – THE CARE PROGRAMME APPROACH (CPA) 98 dangerousness was noted. There was however, a general absence of sensible risk management and the application of recognised techniques to ensure engagement. This is particularly evident in the lack of effort made by psychiatrists to engage Louisa Ovington in structured treatment programmes. There are instances where good work was undertaken, particularly when Louisa Ovington’s care was coordinated by Social Worker 4 and then, Social Worker 7. A great deal of effort was made to identify and plan for Louisa Ovington’s needs, especially housing and training/employment. Realistic attempts were also made to reduce dependence on illicit substances, but in the time leading up to the offence, it appears that Louisa Ovington was increasing her dependence on alcohol and there was little success in resolving this problem. Considering that Louisa Ovington was subject to enhanced CPA during the majority of the time she was involved with mental health services, the panel was concerned about the paucity of written evidence of the use of the CPA in the records generally and disappointed that there was no evidence from the CPA office indicating that they had ensured that the programme was properly monitored and regular reviews held and recorded. These issues are addressed in greater detail elsewhere in the report and appropriate recommendations are outlined in the relevant paragraphs.
Chapter 5 – Involvement with police and probation Note: there are several references in this report to MAPPA (Multi Agency Public Protection Arrangements). It is a matter of great significance that in the case of Louisa Ovington, MAPPA was never invoked. The following, as an introduction to this chapter, should serve as a necessarily brief outline of the MAPPA process. MAPPA CHAPTER 5 – INVOLVEMENT WITH POLICE AND PROBATION The Criminal Justice and Court Services Act 2000 introduced a framework known as Multi-Agency Public Protection Arrangements (MAPPA), under which a duty was placed on the police and probation services (collectively known as ‘The Responsible Authority”) to work together to protect the public from convicted dangerous, violent and sexual offenders living within the community. The Criminal Justice Act 2003 extended the duty to the prison service, who then became the Responsible Authority jointly with the police and probation services. In addition to the duty on the Responsible Authority, this Act placed on various agencies including local authority social care services, primary care trusts, other NHS trusts and strategic health authorities a ‘Duty to Cooperate’ with the Responsible Authority. The aim of MAPPA is to enable the identification of the relevant offender, to provide a formal setting for the sharing of information, to undertake a rigorous risk assessment and to formulate and put into effect a robust risk management plan. The means by which these are achieved are, first, by establishing into which of three categories the offender fits, then managing the offender according to certain criteria. Rigorous risk assessment is a crucial part of the process - without accurate, up to date risk assessment the management of that risk cannot be robust or effective. There are three categories of offenders who may fit the criteria for MAPPA: 1. Registered sex offenders as defined in the Sexual Offences Act 2003; 2. Violent and other sex offenders who have received sentences of imprisonment of more than one year; 3. Other offenders “who are considered by the Responsible Authority to pose a risk of serious harm to the public” 84 who is a category 3 offender is a matter of quite difficult judgement – the Guidance indicates that the person must have a conviction for an offence which shows s/he is capable of causing serious harm to the public and that the Responsible Authority must ‘reasonably consider’ that 84 MAPPA Guidance Probation 2003 99
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REPORT TO THE NORTH EAST STRATEGIC
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Contents CONTENTS Page Preamble 6 I
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Introduction and terms of reference
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The panel met on 14 occasions, tota
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CHAPTER 1 - NARRATIVE OF KEY DATES
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This opinion was referred to by man
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20 May 1998 to 12 January 1999 CHAP
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60. As was common in 1998, there we
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women. Registrar 1 prepared a very
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77. One of the major components of
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visit to see him. A little later, o
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93. The final report from the psych
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surprised and told the panel that h
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• Consultant 9,in his evidence to
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129. Although Louisa Ovington conti
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Page 47 and 48: CHAPTER 1 - NARRATIVE OF KEY DATES
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
Page 61 and 62: 78 21st offence 204. However Louisa
Page 63 and 64: hours. They did not have access to
Page 65 and 66: 210. CPN 2 also completed a risk as
Page 67 and 68: Chapter 2 - Evaluation of the healt
Page 69 and 70: CHAPTER 2 - EVALUATION OF THE HEALT
Page 71 and 72: During Louisa Ovington’s first ad
Page 73 and 74: Kneesworth House Louisa Ovington co
Page 75 and 76: The conclusion drawn by the psychol
Page 77 and 78: On 10 July 2001 Louisa Ovington att
Page 79 and 80: take part in several sessions of a
Page 81 and 82: COMMENT CHAPTER 2 - EVALUATION OF T
Page 83 and 84: CHAPTER 2 - EVALUATION OF THE HEALT
Page 85 and 86: CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 87 and 88: CHAPTER 3 - OUTLINE OF MENTAL ILLNE
Page 89 and 90: CHAPTER 4 - THE CARE PROGRAMME APPR
Page 97: The essence of CPA is to ensure car
Page 101 and 102: 89 ibid The guidance states that th
Page 103 and 104: DS1 told the panel bluntly that, in
Page 105 and 106: and social care agencies. The panel
Page 107 and 108: CRO with a condition of psychiatric
Page 109 and 110: COMMENT The probation officer estab
Page 111 and 112: CHAPTER 5 - INVOLVEMENT WITH POLICE
Page 113 and 114: COMMENT CHAPTER 5 - INVOLVEMENT WIT
Page 115 and 116: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 117 and 118: CHAPTER 6 - RISK ASSESSMENT AND MAN
Page 119 and 120: • South West Durham Mental Health
Page 121 and 122: CHAPTER 7 - PROVISION OF MENTAL HEA
Page 123 and 124: The policy changes were driven by t
Page 125 and 126: • Past psychiatric history; • S
Page 127 and 128: CHAPTER 8 - USE OF THE MENTAL HEALT
Page 133 and 134: Given the multiplicity of agencies
Page 135 and 136: CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 139 and 140: Some of the risk assessments from a
Page 143 and 144: • Recommendation 16. Trusts shoul
Page 145 and 146: f) Use of “talking therapies” C
Page 147 and 148: 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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CHAPTER 9 - CONCLUSIONS AND RECOMME
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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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