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

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PREAMBLE 6 Preamble When Louisa Ovington was five years old she witnessed her father stabbing her mother to death. 22 years later on 8 January 2006 Louisa Ovington killed her former partner Mr Maurice Hilton by a single stab wound to the heart. She pleaded not guilty to murder and on 16 August 2006 was convicted of manslaughter on the grounds of provocation. She received an indeterminate sentence for public protection. In the previous 11 years she had been a patient with several different mental health services. She had been given various diagnoses including drug induced psychosis, personality disorder and alcohol abuse. She had convictions for 30 offences, some of which were violent and involved the use of knives. She had been the subject of three Community Orders (CO)/Community Rehabilitation (probation) Orders (CRO). The panel was very grateful to the close relatives of Mr Hilton who agreed to meet the panel and talked openly with them. The panel wishes to express its condolences to the family who have suffered a dreadful loss.
Introduction and terms of reference The panel was appointed in September 2008 by the North East Strategic Health Authority (SHA) to enquire into the health care and treatment of Louisa Ovington and to deliver to the SHA a report, including findings and recommendations. The investigation was established under the terms of the Health Service Guidance (HSG) (94) 27 as amended in June 2005. The terms of reference were: “To examine the circumstances surrounding the health care and treatment of Louisa Ovington, in particular: • The quality and scope of her health care and treatment, in particular the assessment and management of risk; • The appropriateness of the treatment, care and supervision in relation to the implementation of the multidisciplinary CPA and the assessment of risk in terms of harm to herself or others; • The standard of record keeping and communication between all interested parties; • The quality of the interface between general mental health services and other agencies; • The extent to which her care corresponded with statutory obligations and relevant national guidance; • To prepare a report of that examination for and make recommendations to the North East Strategic Health Authority. The investigation panel consisted of: INTRODUCTION AND TERMS OF REFERENCE • Margaret Crisell, Solicitor-Advocate and Tribunal Judge (Chair). • Dr Clare Chambers, Consultant in General Adult Psychiatry, Bradford District Care Trust. • Tom Welsh, former Head of Nursing and General Manager, Craven Harrogate and Rural District Primary Care Trust. The panel expresses its gratitude to the Tees Esk and Wear Valleys NHS Foundation Trust (TEWV) for their cooperation in the investigation and to the North East Strategic Health Authority for affording the panel the necessary facilities to conduct the investigation. The panel’s independent coordinator was Ms Barbara Milligan, without whose support the panel would have been unable to function and to whom the panel is extremely grateful. 7
Page 1: REPORT TO THE NORTH EAST STRATEGIC
Page 5: Contents CONTENTS Page Preamble 6 I
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 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
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CHAPTER 1 - NARRATIVE OF KEY DATES
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CHAPTER 1 - NARRATIVE OF KEY DATES
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78 21st offence 204. However Louisa
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hours. They did not have access to
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210. CPN 2 also completed a risk as
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Chapter 2 - Evaluation of the healt
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CHAPTER 2 - EVALUATION OF THE HEALT
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During Louisa Ovington’s first ad
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Kneesworth House Louisa Ovington co
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The conclusion drawn by the psychol
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On 10 July 2001 Louisa Ovington att
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take part in several sessions of a
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COMMENT CHAPTER 2 - EVALUATION OF T
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CHAPTER 2 - EVALUATION OF THE HEALT
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
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CHAPTER 3 - OUTLINE OF MENTAL ILLNE
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CHAPTER 4 - THE CARE PROGRAMME APPR
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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
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Given the multiplicity of agencies
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CHAPTER 9 - CONCLUSIONS AND RECOMME
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Some of the risk assessments from a
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• Recommendation 16. Trusts shoul
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f) Use of “talking therapies” C
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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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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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