NHS England is reviewing the quality of training for staff who assess the root causes of homicides by mental health patients.
An NHS England London document, released to HSJ under the Freedom of Information Act, showed significant problems in the way statutory bodies work together to try and prevent the deaths.
The paper, written by NHS England London’s patient safety lead for mental health, said there were problems with the interface between GPs and secondary care; “many investigation reports [were] not identifying key root causes”; and there were “action plans with no key actions being identified”.
In London there are 10 homicides by mental health patients a year, it said.
The paper, produced in July, said other “recurring themes” from trusts’ investigations into these incidents were misdiagnoses and problems caused by “pressures on/changes [to] services”.
One of the key findings was that trusts were producing “action plans with no actions being identified” and “root cause analysis investigations [which were] not identifying key root causes”.
A spokeswoman for NHS England London said: “NHS England London held a multi-stakeholder conference, which included families, in April and this [paper] captures the outputs from the event. The view was that while internal investigations following mental health homicides do include root cause analyses, in some cases a single root cause is not identified.
“All internal investigations include comprehensive action plans but in some cases the actions could be strengthened by being more specific and measurable.”
NHS England has not said who will lead the review, but has been approached for comment.