Abstract
From 1994, individuals in England who are or who have recently been patients of mental health services and who have committed homicide should have their cases independently investigated so any lessons for services can be learnt. This government policy has proved highly controversial and recently has embraced Root Cause Analysis methodology. This article reviews the background to the inquiries and their development. Two hundred and thirty-six inquiries were identified, published between 1995 and 2010. There was a lower proportion of stranger homicides compared to general English homicide statistics. An analysis of recommendations indicated improvement in case management, risk assessment and interagency working. The future of such investigations is discussed.
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