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Independent investigation: Kasey Gordon, Tottenham (2011)

London Incident 20 Jan 2011 Subject Kasey Gordon

Paranoid Schizophrenic fatally stabs schoolboy. Long MH history – previous warnings about knives

Report PDF Hundred Families
Jump to 13 recommendations

Acceptance status

Per recommendation
No Response Published
13
Total recommendations
13
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

13 total
1 The Trust No Response Published
Recommendation
The recommendations and action plan to be reviewed to take account of the Independent Investigation additional findings.
10 The Trust No Response Published
Recommendation
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.
11 The Trust No Response Published
Recommendation
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.
12 The Trust No Response Published
Recommendation
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.
13 The Trust No Response Published
Recommendation
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.
2 The Trust No Response Published
Recommendation
The Trust to ensure that the action plan continues to be monitored and its progress reported upwards via its governance reporting systems.
3 The Trust No Response Published
Recommendation
The Trust should include an audit and/or process within the Internal Investigation action plan to ensure compliance with each recommendation.
4 The Trust No Response Published
Recommendation
The Trust should assure itself that leadership development is an ongoing process leading to effective leadership at both clinical and managerial level.
5 The Trust No Response Published
Recommendation
The Trust should assure itself that the findings from Internal reports are acted upon in a timely manner.
6 The Trust No Response Published
Recommendation
The Trust should assure itself that Root Cause Analysis training is available to any person who is a member of an Internal Investigation panel.
7 The Trust No Response Published
Recommendation
The Trust should ensure that all recommendations from Internal Investigations are SMART and auditable, leading to effective learning.
8 The Trust No Response Published
Recommendation
The Trust should ensure that all Policies are current and that there is a process described to monitor compliance with each.
9 The Trust No Response Published
Recommendation
The Trust should assure itself that the process described in the Organisational Change Policy is audited to ongoing compliance.