Lousia Ovington independent investigation report ... - NHS North East
Lousia Ovington independent investigation report ... - NHS North East Lousia Ovington independent investigation report ... - NHS North East
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS 46 137. Social Worker 5 visited her on 13 November and was told that things were more under control but she was splitting up with Mr Hilton. 138. On 15 November 2003 ( two days later) the police were telephoned by Louisa Ovington several times, reportedly very drunk, including a call informing them that she had stabbed Mr Hilton and he was lying dead. When the police arrived he was not there. The truth of what happened is not known. It is not known whether the police made contact with the CMHT about this. 139. On 7 December 2003 Social Worker 5 visited Louisa Ovington and noted that she was low in mood. Louisa Ovington told her that she had seen CAS 2, (although the panel found no evidence of this) and that there had been domestic violence. She was given the name of agencies to contact, but she did not do so. 140. Social Worker 5 may have been on sick leave in January; at any rate she did not see Louisa Ovington until February 2004. 141. On 12 February 2004 Social Worker 5 visited Louisa Ovington. Louisa Ovington said that she had been drinking excessively; that things were “terrible” in her relationship; and that she may have had “some psychosis” recently. She had missed her appointments with CAS 2. Her father wanted her to move to Edinburgh. Social Worker 5 advised her to make another appointment with CAS 2 and to reduce her alcohol intake. Social Worker 5 told Louisa Ovington that she was leaving her post and the next visit would be her last. 142. On 24 February 2004 Social Worker 5 visited for the last time. She recorded that Louisa Ovington agreed that she did not need any further input from the team but that she would continue to attend outpatients with Consultant 2 (although there is no evidence that she had ever attended any appointments with Consultant 2). Louisa Ovington was told that the case was closed to social services but that it was ‘still open’ to the CMHT whom she could contact at any time and that she was still entitled to Section 117 aftercare. The new care coordinator was to be Consultant 2. Social Worker 5 wrote to him on 30 March (over a month later) to inform him of this. There is no evidence of any coordinated planning or discussions, nor that Consultant 2 agreed to take over. COMMENT • It is recognised that it can be very difficult for patients when they are passed from one worker to another. It appeared to the panel that Social Worker 4 did his best to ensure a smooth handover to Social Worker 5. Nonetheless it also appeared to the panel that Louisa Ovington’s behaviour deteriorated following
CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS the transfer of care: soon afterwards she was involved in a physical altercation with a woman, she drank excessively and she quarrelled a lot with Mr Hilton. • Although Social Worker 5 was a member of the CMHT which should have enabled access to a broad range of support for Louisa Ovington, in comparison with the level of support she had received from the previous care coordinator, there was a noticeable reduction in the service offered. This culminated in Louisa Ovington apparently agreeing that she did not need social worker support and the case being closed to social services, despite the fact that Louisa Ovington’s presentation remained unchanged and her problems had not diminished. There is no evidence that Social Worker 5 employed effective techniques to ensure Louisa Ovington’s engagement with the services. • In the panel’s opinion it was inappropriate when Social Worker 5 left, for Louisa Ovington not to be allocated a care coordinator from the CMHT. Her mental state remained fragile and she had only recently admitted to drinking excessively most days. Louisa Ovington was told that she could contact the CMHT manager if she felt the need, but it was well known that her engagement with services was limited and (in the panel’s view) it was obvious that she was most unlikely to do this. • Although the case was closed to social services Louisa Ovington remained subject to CPA, yet there is no evidence to suggest any arrangement to hand over to another care coordinator apart from a letter to Consultant 2, nominating him as care coordinator. There is nothing in the records to indicate that Louisa Ovington ever met Consultant 2. It is evident that he was not asked if he could take on this role: he was simply written to and informed that he was to do so. Furthermore, Staff Grade Psychiatrist 1 told the panel that Louisa Ovington was not under the care of Consultant 2 at this time; she was under the care of Consultant 13, who was Staff Grade Psychiatrist 1’s supervising consultant. It appeared from what Staff Grade Psychiatrist 1 said to the panel that at that time there was little correlation between the named care coordinator on CPA documents and who actually took on the role. • Staff Grade Psychiatrist 1 was a locum staff grade doctor at this time. It proved impossible for the panel to clarify which of the consultants was his supervisor, there being so many changes in consultants. In any case, Staff Grade Psychiatrist 1 told the panel that he had “very, very minimal supervision”. From the records it appears that Staff Grade Psychiatrist 1 effectively took over the role of care coordinator, but it is unclear whether or not he ever did so officially. 47
- 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 15 and 16: CHAPTER 1 - NARRATIVE OF KEY DATES
- Page 17 and 18: 20 May 1998 to 12 January 1999 CHAP
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- Page 21 and 22: CHAPTER 1 - NARRATIVE OF KEY DATES
- Page 23 and 24: 60. As was common in 1998, there we
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- 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
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- Page 37 and 38: surprised and told the panel that h
- Page 39 and 40: • Consultant 9,in his evidence to
- Page 41 and 42: CHAPTER 1 - NARRATIVE OF KEY DATES
- Page 43 and 44: 129. Although Louisa Ovington conti
- Page 45: CHAPTER 1 - NARRATIVE OF KEY DATES
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- 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
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- 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
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CHAPTER 1 - NARRATIVE OF KEY DATES AND EVENTS<br />
46<br />
137. Social Worker 5 visited her on 13 November and was told that things were more<br />
under control but she was splitting up with Mr Hilton.<br />
138. On 15 November 2003 ( two days later) the police were telephoned by Louisa<br />
<strong>Ovington</strong> several times, <strong>report</strong>edly very drunk, including a call informing them that she<br />
had stabbed Mr Hilton and he was lying dead. When the police arrived he was not<br />
there. The truth of what happened is not known. It is not known whether the police<br />
made contact with the CMHT about this.<br />
139. On 7 December 2003 Social Worker 5 visited Louisa <strong>Ovington</strong> and noted that<br />
she was low in mood. Louisa <strong>Ovington</strong> told her that she had seen CAS 2, (although<br />
the panel found no evidence of this) and that there had been domestic violence. She<br />
was given the name of agencies to contact, but she did not do so.<br />
140. Social Worker 5 may have been on sick leave in January; at any rate she did not<br />
see Louisa <strong>Ovington</strong> until February 2004.<br />
141. On 12 February 2004 Social Worker 5 visited Louisa <strong>Ovington</strong>. Louisa <strong>Ovington</strong><br />
said that she had been drinking excessively; that things were “terrible” in her<br />
relationship; and that she may have had “some psychosis” recently. She had missed<br />
her appointments with CAS 2. Her father wanted her to move to Edinburgh. Social<br />
Worker 5 advised her to make another appointment with CAS 2 and to reduce her<br />
alcohol intake. Social Worker 5 told Louisa <strong>Ovington</strong> that she was leaving her post and<br />
the next visit would be her last.<br />
142. On 24 February 2004 Social Worker 5 visited for the last time. She recorded<br />
that Louisa <strong>Ovington</strong> agreed that she did not need any further input from the team<br />
but that she would continue to attend outpatients with Consultant 2 (although there<br />
is no evidence that she had ever attended any appointments with Consultant 2).<br />
Louisa <strong>Ovington</strong> was told that the case was closed to social services but that it was<br />
‘still open’ to the CMHT whom she could contact at any time and that she was still<br />
entitled to Section 117 aftercare. The new care coordinator was to be Consultant 2.<br />
Social Worker 5 wrote to him on 30 March (over a month later) to inform him of this.<br />
There is no evidence of any coordinated planning or discussions, nor that Consultant 2<br />
agreed to take over.<br />
COMMENT<br />
• It is recognised that it can be very difficult for patients when they are passed<br />
from one worker to another. It appeared to the panel that Social Worker 4 did<br />
his best to ensure a smooth handover to Social Worker 5. Nonetheless it also<br />
appeared to the panel that Louisa <strong>Ovington</strong>’s behaviour deteriorated following
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