Recommendation
A consistent approach to clinical risk assessment should be developed across London (NB the London Mental Health Trust CEO Group is preparing a two year improvement programme in this area).
Recommendation
Exemplar practice regarding the procedures, management and governance arrangements of SUIs should be disseminated across the sector, as should wider learning from SUIs.
Recommendation
Trust Boards should take the lead in ensuring that procedures, management and governance arrangements are clear, effective and well resourced.
Recommendation
The Trust needs to ensure that all internal investigations are completed within 60 days utilising a root cause analyses methodology.
Recommendation
Senior clinical input must be considered as part of the Multi Agency Public Protection Agency process. This input should take the form of a Consultant Psychiatrist.