Independent investigation: Harry Messenger, Faversham (2017)

Trust SI reports should set out the evidence and analysis used to form judgements as to whether practice was undertaken in line with Trust policy.

The Trust should enforce its assurance and sign off process/policy for serious incident reports.

The Trust should review its action plan process to strengthen action sign off, specifically:
 A section in the action plan template to assign individual and/or executive team
responsibility for signing off actions
 Details of executive team oversight
 The names and roles of individuals responsible for signing off actions.

The template for ‘Referral not accepted’ should include a signpost to copy the GP into the letter in instances when the GP was not the original referrer.

The Trust needs to further assure itself, by way of audit, that GPs, patients and referring teams are being informed of a CMHT decision to not accept a patient.

The Trust wide Patient Safety and Mortality Review Group should undertake an audit of the last 12 months of investigations to assure itself that the Trust adheres to Duty of Candour.

Canterbury and Coastal CCG should seek to assure itself, as a priority, that it is signing off Trust SI reports in line with CCG policy and the NHSE SI framework, and that Trust action plans are appropriately tested, monitored and reviewed.