Independent investigation: Kasey Gordon, Tottenham (2011)

The recommendations and action plan to be reviewed to take account of the Independent Investigation additional findings.

The Trust must ensure that CCs, with appropriate support and clear managerial direction, follow the professional requirements of their role, and that a system is put in place to measure compliance with this.

The Trust should ensure that it does not use Panel members who have had other involvement with the issue being investigated, or where this is not possible it is declared within the report.

The Trust should ensure that where new services are set up in the community, it carries out impact assessments which identify any implication of safety for the public and put in place plans to these mitigated the risks identified.

The Trust must ensure that given the new commissioning arrangements for Forensic Services, no gap is allowed to develop for Service Users to fall between General and Forensic psychiatry.

The Trust to ensure that the action plan continues to be monitored and its progress reported upwards via its governance reporting systems.

The Trust should include an audit and/or process within the Internal Investigation action plan to ensure compliance with each recommendation.

The Trust should assure itself that leadership development is an ongoing process leading to effective leadership at both clinical and managerial level.

The Trust should assure itself that the findings from Internal reports are acted upon in a timely manner.

The Trust should assure itself that Root Cause Analysis training is available to any person who is a member of an Internal Investigation panel.

The Trust should ensure that all recommendations from Internal Investigations are SMART and auditable, leading to effective learning.

The Trust should ensure that all Policies are current and that there is a process described to monitor compliance with each.

The Trust should assure itself that the process described in the Organisational Change Policy is audited to ongoing compliance.