NHS failures contributed to two people being killed by a man with schizophrenia after he was freed from a secure hospital, two inquiries suggest.
Peter Bryan, 39, of east London, killed a friend and ate parts of his brain in 2004 - two years after being released from Rampton, in Nottinghamshire.
He then went on to kill a patient after being sent to Broadmoor.
The independent reports into the deaths said while Bryan was a unique case, more should have been done to stop him.
The inquiries, carried out for NHS London, the body which oversees health services in the capital, blamed system failures instead of individuals for the mistakes.
However, they acknowledge he was a difficult case because he could go through long periods without showing any signs of overt mental illness.
Bryan was first sent to Rampton secure hospital after beating 20-year-old shop assistant Nisha Sheth to death with a hammer in 1993.
In 2002 he was released into the community after applying to a mental health tribunal and allowed to live as a care in the community out-patient.
He was sent to a hostel where residents have their own front door and room key.
But after an allegation of an indecent assault on a 17-year-old girl, Bryan was sent back to hospital, but this time he was only an informal patient on an open ward at Newham General Hospital in east London.
In February 2004, he walked out of the unit and killed his friend Brian Cherry, 45, before frying and eating parts of his brain. He had also started to dismember the body.
He was arrested and after appearing in court was sent to another secure hospital, Broadmoor.
Within weeks of arriving, Bryan attacked fellow patient, Richard Loudwell, 59, who later died.
In court, he pleaded guilty to killing both men on the grounds of diminished responsibility.
One psychiatrist who interviewed Bryan concluded that he was "probably the most dangerous man he had ever assessed".
Full article: BBC News
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