Failings in the care of mental health patients convicted of murder or manslaughter are regularly taking up to five years to put right, an investigation by hsj.co.uk has revealed.
Patients and the public are being needlessly put at risk by the 'unacceptable' amount of time it takes to make improvements, mental health charities have warned.
In one case, concerns arising from a murder that took place more than a decade ago are yet to be fully tackled.
The delays are being blamed on police inquiries, NHS reorganisation and accusations of deliberate 'foot-dragging' by strategic health authorities, which are responsible for commissioning independent reports and tracking trusts' progress in implementing any recommendations.
Still waiting for action
Many of the recommendations yet to be implemented focus on improving information-sharing, record-keeping, risk assessment training and the care programme approach, which sets out how a patient's care should be co-ordinated across different agencies.
Hsj.co.uk's investigation found there are currently 27 outstanding cases, and seven of the 10 strategic health authorities are yet to implement recommendations arising from incidents that took place three years ago or more.
In England, there are around 50 murders or manslaughters each year by people who have recently been treated for mental illness.
Mental Health Foundation chief executive Andrew McCulloch claimed it should take no longer than three to six months after a court conviction to change practices criticised in independent inquiries.
'Taking several years isn't acceptable. The process needs to be much quicker and more efficient,' he told hsj.co.uk.
'Currently it's consuming a huge amount of resources, without a great deal of evidence that it's protecting patients or the public.'
Oxleas mental health foundation trust chief executive Stephen Firn agreed that the process should be quicker.
'We have a responsibility to properly investigate things to ensure that families and the public know what's happening, and also so that the [trust] board follows them up,' he said.
'It should be the utmost priority that these things are implemented and I'm not sure what would take priority over that. It's down to local leaders to give it the sufficient energy and focus.'
After a killing
Whenever a murder or manslaughter is committed by someone who has used mental health services in the previous six months, the SHA concerned must commission an independent inquiry. The trust may also carry out an internal investigation.
Last month, NHS chief executive David Nicholson ordered all strategic health authorities to conduct audits after it was discovered that external investigations were not carried out for 26 cases in London over a five-year period to December 2006.
Strategic health authorities usually wait for court cases to finish before commissioning independent investigations, even though vague Department of Health guidance issued in January 2005 gave the impression investigations could begin immediately.
Criticism of the process
This is unnecessarily stalling the process, claim critics such as Michael Howlett, director of mental health charity the Zito Trust, which was set up in 1994 to help families of people killed by mental health patients.
Mr Howlett told hsj.co.uk: 'There's always a lot of stalling and foot-dragging by the SHA, which I think is deliberate. It takes the heat off the case and the spotlight goes off them.'
He argued that there should be a statutory limit on the amount of time taken to commission and implement action plans, with a monitoring body to check that changes have been made.
John Finnegan, whose brother Denis Finnegan was stabbed to death by paranoid schizophrenic John Barrett while cycling through Richmond Park in 2004, agreed, calling the delays 'horrendous'.
The health service view
But it would be wrong to accuse strategic health authorities of deliberate inertia, according to Peter Blythin, director of nursing and workforce at West Midlands strategic health authority, which is monitoring three outstanding cases.
Trusts often make significant changes on their own before external inquiries report back, he said.
'It's complicated by the fact that police inquiries take a long time and sometimes information is protected or we're asked not to interview people in case it prejudices the case,' he said.
Merging 28 strategic health authorities into 10 in England last July also slowed action down, creating a 'hiatus' while handovers took place, he claimed.
'Everybody acknowledges that the process could be slicker. It could be done better right across the country.'
Mental health investigations should take a long time, according to Ed Marsden, a former NHS manager who now runs a consultancy, Verita, that helps organisations setting up independent inquiries.
'Smaller investigations can be done in three weeks, but mental health is very complex and involves many different agencies,' he said.
'My experience of SHAs and trusts is that they like investigations to be carried out in a focused and proportionate and thorough way.'
Taking more than a decade
In the most notorious case, actions are yet to be signed off for the 1996 murder committed by drug addict Michael Stone, who bludgeoned Lin Russell and her six-year-old daughter Megan to death and left her elder daughter, nine-year-old Josie, with serious head injuries.
An independent report had been completed in November 2000 but was shelved for six years until last December pending court appeals and a judicial review brought by Stone.
Peter Hasler, director of nursing at Kent and Medway Partnership Trust, which is dealing with the case, said because the report was not released, the information it contained could not be shared with all staff across the relevant agencies.
'Releasing a report in 2006 for a murder in 1996 is an awfully long delay and things will be irrelevant. The names of organisations don't even exist anymore.
'Almost without exception, most people named in the report have moved on.'
The trust is yet to implement the report's call for better 'low-secure services' - low-security inpatient wards. 'It's about getting the funding so is largely a commissioning issue,' Mr Hasler said.
Hsj.co.uk has learned that the National Patient Safety Agency will bring out new guidance within the next two months that will limit the time trusts have to carry out internal investigations to three months.
At present, the guidance states only that local investigations should start 'as soon as possible after the adverse event'.
Under the new guidance, urgent policy changes will have to be made within 72 hours after the incident.
The agency's mental health lead, Ben Thomas, said: 'We want more consistency in methods and timing. There's a safety issue here.'
However, the agency has no remit over the length of time independent investigations reports take to be written or implemented.