Independent investigation: Gerry Fairall, Kilburn, London (2006)

The Trust should as a matter of urgency commission a piece of work to look at possible gaps in governance around the management of service users being seen in outpatients alone.

The Trust should ensure that it regularly audits the implementation of the CPA policy. The auditing process should account for the quality of information available as well as quantitative measures.

The Trust should review its teaching and training relating to CPA to ensure that all staff have a clear understanding of the purpose of CPA, and their roles and responsibilities within the CPA framework.

The Trust must have procedures in place to guarantee staff have easy access to all service user files which have relevant background information included in a consistent and easy to find format.

The Trust should ensure that all staff are aware of the importance of service user involvement and the inclusion agenda. This is particularly the case when carrying out a needs assessment and formulating a care plan. Mandatory training should be provided on this.

The Trust should examine its systems for risk assessment and risk recording to ensure that staff have easy access to comprehensive information at any time. This process should be regularly audited. Again mandatory training should be provided on this.

The Trust should review their Patient Transfer policy. We would recommend that in such circumstances patients should not be transferred when in relapse unless absolutely essential, and that handover of care should be evidenced by care co-ordinators.

We recommend that the lessons learned from this investigation should be disseminated to all staff and put together into an action plan for implementation.