Two reports into psychiatric patients who killed have been released by NHS East of England - more than five years after the incidents.
Gary Roberts and Derek Field were patients of South Essex Partnership foundation trust. It carried out internal reviews after the deaths in December 2002 and January 2003. It then ordered full independent reviews, but has only just released them, 10 months after they were delivered to NHS East of England.
The SHA said the time taken to publish the reports "was longer than we would have liked... due to a delay in identifying membership of the panel, in getting the required consent for the release of patients' records, securing the involvement of key witnesses, the reconfigurations of strategic health authorities in 2006 and ensuring the relatives and families were aware of publication".
The review panels highlight the difficulty in establishing what happened so long after the events. The reports follow an hsj.co.uk investigation last year that revealed it often takes years to improve services after mental health patients kill.
The reports are critical of aspects of the two men's care, who were both diagnosed with schizophrenia. They highlight the need for better communication between healthcare professionals and with relatives and the need for better staff supervision.
Trust chief executive Patrick Geoghegan said it had established crisis teams and now provided immediate access to inpatient services.
HSJ's Transforming Forensic Mental Health Services conference is on 24 June, www.hsj-forensicmentalhealth.co.uk