Independent investigation: PC Johnathan Henry, Luton (2007)

An audit be undertaken to assure the trust that key staff are aware of the CPA and disengagement policies.

Review team caseloads annually and ensure team managers review care coordinator workloads on a monthly basis.

Undertake a review of mandatory training for CPA, practice risk assessment and practice risk management for attendance, capacity and quality.

Ensure all those with management responsibilities are engaged in appropriate leadership activities which sit within a framework for leadership across the organisation and which are clearly recorded in appraisal and development paperwork.

Undertake a review and ensure clinical risk assessments and risk management systems are in line with best practice guidance published by the Department of Health in 2007 and other relevant national best practice.

Review support and supervision arrangements for team managers and ensure existing policy reflects national best practice.

A standardised pro forma should be introduced for conducting and recording CMHT meetings, which addresses the consideration of issues such as risk, complex cases and handover between teams and care coordinators.

Develop and implement a plan for the creation of unitary service user clinical records in line with national best practice.

All service changes likely to impact on the quality of patient care should be risk assessed as part of the broader business case for change, and detailed risk assessment carried out where the risk is significant. Risk assessments must be shared with commissioners where relevant.

We recommend that the commissioning PCTs and SEPT ensure that all service changes are monitored by senior managers to ensure that agreed processes are followed.

We recommend that SEPT review its non-concordance and disengagement policy within six months. The change should ensure that the policy is clear what action should be taken in circumstances where a community service user is partially engaged as happened in the case of TO.

We recommend that PCTs and SEPT should consider carefully BLPT recommendation 9 and that PCTs and SEPT must not agree to implement service changes unless they have been provided with adequate evidence that the actions set out in the recommendation have been followed and the risks of change have been effectively assessed.

We recommend that the PCT should report to the SHA within six months on the progress that SEPT has made on implementing our recommendations and the continuing progress it has made with the recommendations contained within the final BLPT RCA report as set out below.