Paradise Coldplay Download 'Paradise' on iTunes
A new report say North Essex NHS Trust missed opportunities to prevent killings by mental health patients in its care.
The murders happened during a 3 year period and the review highlighted poor risk assessments and a lack of information-sharing.
The trust's produced an action plan to make sure recommendations are acted on.
Andrew Geldard, Chief Executive of NEPFT, made the following statement: "These reports are the last part of the legal process that must follow wherever there is a homicide.
We have no desire to make things any worse for the families and friends of the victims of these crimes, who must be in our thoughts.
The investigations are necessary to examine whether improvements can be made in systems; we welcomed the grouping of cases involving North Essex together as an efficient and coordinated way of looking into events of the past.
Minor Improvements were recommended, we accepted these and they have been carried out. In most cases the investigations found that the crimes were not predictable or foreseeable, even though system improvements could have been made in the care process. "Learning lessons" sounds like shutting the stable door after the horse has bolted, but this is not the case. There have been police prosecutions and coroners' investigations; the Trust also investigated the issues. But we must always see if there is something more the NHS could have done; system changes can help make thinking clearer and identify issues that might lead onto practice change. This we have done."