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

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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 20 48. The panel noted that the medical and nursing staff differed in their opinions as to diagnosis. Sister 1 told the panel that she would be surprised to hear that Louisa Ovington had a psychotic illness. Her view was that Louisa Ovington had personality problems with psychotic symptoms. When seen by the panel Consultant 5 however was equally firm in his conviction that Louisa Ovington was suffering from a psychotic illness. 49. It was clear from a fairly early stage in her stay at the Tony White Unit that it was not geared to the particular demands that Louisa Ovington was making upon the staff. It was a very small, locked Psychiatric Intensive Care Unit (PICU) that focussed on the intensive, speedy resolution of acute distress as part of a serious mental illness. (One of the nurses eloquently described the physical surroundings to the panel, saying “the atmosphere was sometimes like a tinder box”.) Consultant 5 and his staff felt that it could not provide the structured, consistent and predictable management plan that Louisa Ovington required. He told the panel (and indeed many people at the time), that he was concerned for the safety and well being of his staff. He therefore began to look for alternative forensic placements for her. 50. Between September and November 1998, Consultant 5 approached several medium secure forensic units in his search for another placement. The Hutton Unit in Middlesbrough (part of St Luke’s Hospital) declined to take her as she had assaulted relatives of members of staff who then worked there. The consultant at Wakefield felt that it would be too far from her home, with consequent difficulties in resettling her. The Roycroft Unit at St Nicholas Hospital, a medium secure adolescent unit in Newcastle, had no beds but did send a forensic nurse and a forensic psychologist to assess her and provide advice on her management. 51. The detailed psychometric/psychological assessments carried out by the clinical psychologist from the Roycroft Unit concluded, amongst other things that Louisa Ovington was “a violent young woman” who was “highly manipulative, impulsive and difficult to manage”; that she was likely to have a selfish, callous and remorseless interpersonal style; that she had little motivation to change and that she was not suitable for an adolescent unit, but that there should be a further full assessment for psychopathy. 52. Consultant 9 from St Nicholas Hospital Medium Secure Unit in Newcastle, also assessed Louisa Ovington. He said the most likely diagnosis was schizophrenia. He said that Louisa Ovington fully accepted that there were times when she had acted very dangerously and that she had admitted that she “could have killed someone” at the time when she was running about with a knife. He thought that the Crown Prosecution Service should continue with charges against Louisa Ovington (for the assaults on the nursing staff) despite her being on a Hospital Order, because her past
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS behaviour combined with severe mental illness meant that it would be appropriate for a Crown Court to decide whether or not a further Hospital Order should have restrictions imposed on it under Section 41 of the Mental Health Act 27 as this would assist her future management. At this stage however (November 1998) he did not think that Louisa Ovington needed to be transferred to the medium secure unit in Newcastle: she was being adequately managed in a low secure facility and the fact that she was being given escorted leave in the community did not support the suggestion that she needed to be placed in a more secure environment. 53. Consultant 9 told the panel that at this time the NHS forensic services tended to run at 100% full and to a large extent the forensic consultants had to act as “quite severe gatekeepers” only offering places in medium security if the patients really could not be managed in low security. 54. Consultant 5 had also approached Hartlepool General Hospital and Louisa Ovington was assessed by Consultant 7 who had prepared a second opinion for the court hearing in August 1998 (see paragraph 38) to see if she might be suitable for their open adult psychiatric ward. Consultant 7 recognised that Louisa Ovington was more stable than she had been when he had previously interviewed her but nonetheless felt she was not suitable as she still needed clearly cut, defined and closed boundaries. He thought she was suffering from bipolar affective disorder and personality disorder. 55. In November 1998 Louisa Ovington was arrested for three further assaults on nursing staff, but was not prosecuted (they were apparently dealt with as “TICs” 28 ). 56. On 14 December 1998 Louisa Ovington was due to appear in court again in relation to the assaults on nursing staff. Consultant 5 told the court that he could not accept liability for inpatient care for more than a further week because he was so concerned for the safety of his staff. Furthermore, he said in his report for the court that Louisa Ovington had developed a vengeful dislike against particular nurses, which he considered had a very dangerous potential. He described the arrangements at the Tony White Unit as ‘unsafe in the extreme’. At this stage he indicated that he believed that Louisa Ovington had largely recovered from her mental illness (through treatment) but that she still had a considerable residual psychopathic disorder. He thought that in view of the severity of the threat which she posed to a number of people it was appropriate for the matter to be referred to the Crown Court for a Section 41 Restriction Order 29 to be imposed and said that he thought Louisa Ovington should be in a regional secure unit. The case was adjourned to January 1999. 27 See Chapter 8 28 TIC’s- offences ‘taken into consideration’ when sentencing for other offences 29 See Chapter 8 21
Page 1: REPORT TO THE NORTH EAST STRATEGIC
Page 5 and 6: Contents CONTENTS Page Preamble 6 I
Page 7 and 8: Introduction and terms of reference
Page 9 and 10: The panel met on 14 occasions, tota
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 19: CHAPTER 1 - NARRATIVE OF KEY DATES
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
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
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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 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
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
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Given the multiplicity of agencies
Page 135 and 136:
CHAPTER 9 - CONCLUSIONS AND RECOMME
Page 137 and 138:
Page 139 and 140:
Some of the risk assessments from a
Page 141 and 142:
Page 143 and 144:
• Recommendation 16. Trusts shoul
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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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Page 155 and 156:
LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • Recomme
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LIST OF RECOMMENDATIONS • The pol
Page 161 and 162:
Bibliography 1. Effective Care Coor
Page 164:
INTRODUCTION 28 North East Strategi
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