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

CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS
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• There was no record of the home authority being involved in discharge
arrangements or Consultant 9 having been consulted or even informed prior
to discharge. The effect of this was that there was no opportunity for a
well planned handover to the home services.
• Forensic services should have been involved ( they were the agency that referred
Louisa Ovington to Kneesworth House) and it was made clear to the panel that
in view of Louisa Ovington’s history they were expecting and willing to be
involved with her post discharge.
• It is regrettable that Consultant 9 (the referring consultant) was not contacted
when Louisa Ovington’s discharge from Kneesworth House was first considered.
He told the panel that his team would have been able and willing to provide
follow up in the community. Louisa Ovington was known to have difficulties
with engagement. She was much more likely to engage with a team she
already knew than with people with whom she had no prior relationship.
• The rationale for Louisa Ovington not meeting the criteria for further detention
was not clearly explained. There was a contradiction in the fact that the clinical
team at Kneesworth House expressed the view that Louisa Ovington was not
suffering either from mental illness or from a personality disorder yet were
taken aback and concerned when the home community team accepted the
probation view that since there was no mental illness there was no need for
probation with a condition of psychiatric treatment.
• In March 1999, government policy was published which defined the new
arrangements for Effective Care Co-ordination 46 . This drew together the previous
arrangements for the CPA and the previous arrangements for care management
which had been the responsibility of social services departments and required
staff to work together to ensure that effective discharge arrangements were
in place particularly for those under enhanced CPA ( which Louisa Ovington
was). Under these terms the care planning prior to discharge fell well short
of what might have been expected. The home social services team was clearly
concerned about this and a full meeting was held on 24 January. However
it appears that of the important elements of the care plan none was effectively
implemented: Louisa Ovington did not see her Key Worker (Social Worker 2);
she did not wish to be referred to drug and alcohol services; she was not
assessed by the CPN service; no referral was made to Stonham Housing and she
did not attend any outpatient appointments with Consultant 12.
46 See Chapter 4