Hsj.co.uk's investigation found there are 27 outstanding cases where recommendations following a murder or manslaughter by a mental health patient have not yet been fully implemented.

Seven of the 10 strategic health authorities are yet to implement recommendations arising from incidents that took place three years ago or more.

NHS North East is monitoring one outstanding case, following the manslaughter of two men in their 20s by paranoid schizophrenic Sean Crone on 30 October 2003.

An independent inquiry was commissioned in May 2005, which reported back in January 2007.

Recommendations yet to be fully implemented by the strategic health authority include:

  • Developing a mentally disordered offender strategy that fosters inter-agency working and services for mentally ill offenders.

  • Developing alternative models such as crisis intervention, early intervention in psychosis and assertive outreach teams.

  • Encouraging primary care commissioners to promote detailed record-keeping.

  • Monitoring standards of clinical information exchange.

  • Promoting better understanding of the available and appropriate care pathways between services.

  • Ensuring the care programme approach is used.

  • Using more direct referrals and freeing care pathways from obstruction.

  • Ensuring ready access to mental health professionals for patients using acute hospital services.

  • Sunderland mental health services need to develop a strategy to engage individuals who are reluctant to access services.

A spokeswoman stressed that no causal link had been found between Sean Crone’s care and the two deaths.

'The strategic health authority will continue to work with the trust [Northumberland, Tyne and Wear trust] to ensure progress against the action points, which should all be completed by December 2007,' she said.

NHS Yorkshire and the Humber has two outstanding cases, both relating to incidents in 2003.

One will be signed off following an audit on the effectiveness of induction procedures for new staff, due to take place in September.

The second case highlighted problems with record-keeping that it says cannot be resolved until the roll-out of the electronic records system, part of the NHS National Programme for IT.

However, the SHA wishes to close the cases and will discuss this further at its September board meeting.

A spokeswoman said: 'We recognise that in the past there have been delays in the commissioning process of independent inquiries and the follow up in some cases.

'The SHA board now takes an active interest in the regular updates and ensures vigorous follow-up of action plans.'

NHS South Central is yet to fully address three out of 14 issues identified in an independent inquiry after a patient of Buckinghamshire Mental Health trust stabbed a young man in a Chesham park in August 2004. These include:

  • listing patients' previous contacts with other services in patient assessments;

  • staff training;

  • re-auditing a review of the duty system.

These are due to be completed by the end of September.

NHS South West is still working on problems highlighted after paranoid schizophrenic Matthew Newland stabbed his 79-year-old neighbour to death in Bristol in March 2002.

Board papers indicate ongoing work in the following areas:

  • using records effectively;

  • care programme approach care plans and trust-wide register;

  • nursing and social work skills assessments;

  • discharge summaries;

  • home visits following missed appointments;

  • support for carers;

  • early intervention services;

  • integrating health and social care.

A spokeswoman said: 'A multi-agency implementation group continues to meet every two months to monitor and steer further work to ensure full compliance with recommendations.

'The multi-agency group will meet until the final review of progress by the inquiry panel, which reports to the March 2008 SHA board.'

NHS West Midlands is reviewing three cases. The oldest dates back to November 2002, when a patient killed his elderly neighbour. Work is continuing in the following areas:

  • staff appraisals;

  • care programme approach delivery plan;

  • assessment of forensic liaison service;

  • care programme approach audit;

  • developing a primary care trust risk management staff bulletin;

  • revising policy for reporting incidents in line with national guidance.

A spokeswoman said work had commenced on all recommendations.

She said: 'The SHA will be further reviewing the plan in September 2007 and expects the above outstanding recommendations to be completed by the end of the year.'

Progress against reports for the independent inquiries into the treatment of two other cases - both from 2005 - are planned for review later this month.

In addition, there are five cases awaiting action plans.

NHS South East Coast is working on recommendations arising from nine cases. Most of these date back to incidents from 2000 to 2003, apart from the 1996 Michael Stone case and a manslaughter in 1998.

Several of these focus on care plans, the care programme approach and risk assessment training.

The action plans can be found at the links below. In some cases, names have been withheld to uphold the confidentiality of patients, victims and their families.

Mr H killed his acquaintance Mr G in August 2003.

NHS South East board papers containing the independent investigation report

Michael Stone (see separate case study)

Report of the independent investigation

Mr P killed his former girlfriend Ms E at her flat in March 2003.

Mr M killed his partner Ms L in June 2002.

Surrey and Sussex SHA board papers containing the independent investigation report

Q, a young women who had been subjected to terrible abuse as a child, killed her partner in 2000.

Mr A, 35, killed his partner Ms B, 26, at their flat in Surrey in August 2001.

Woking mother of four Ms X stabbed her friend to death in June 2001.

Surrey and Sussex SHA board papers containing the independent investigation report

18-year-old Gemma Hearn fatally stabbed Mark Blackston at her Northfleet home in June 2001.

Mr R stabbed a man in Ramsgate on 28 September 1998, and stabbed and killed another man the next day

Reports of the independent investigation

NHS London has five outstanding cases dating back to 2002. Recommendations from independent inquiries where work is still ongoing include the establishment of emergency team response targets, risk assessment training, and care programme approach development.

Mariam Miles stabbed her schoolteacher husband, Edward Miles, to death in July 2004.

Independent investigation report

In June 2003, healthcare assistant Eshan Chattun was attacked and killed by Jason Cann, a patient at Springfield Hospital in Tooting.

Independent investigation report

Stephen Soans-Wade pushed Christophe Duclos into the path of an oncoming tube at Mile End station in September 2002.

Independent investigation report

John Barrett killed Denis Finnegan as he cycled through Richmond Park in September 2004 (see separate case study).

Independent investigation report

Dennis Foskett killed his partner in July 2003.

Independent investigation report

NHS North West, NHS East Midlands and NHS East of England are not currently monitoring any cases.