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In 1994 the Department of Health published its guidance on the discharge of mentally disordered people and their continuing care in the community (HSG (94) 27) which established, for the first time, that when a mental health service user kills someone “it will always be necessary to hold an Inquiry which is independent of the providers involved” . The independent investigation (as these inquiries are now called) would take place after the completion of any legal proceedings and its purpose was stated to be: “To learn lessons for the future” . The independent investigation would be commissioned by the responsible strategic health authority, which would also decide on whether to publish it and, if so, in what form.

‘Publicity v Privacy: finding the balance’ When and how to publish reports of mental health homicide independent investigations