NHS failures contributed to two people being killedby 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 afterbeing 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.
Theinquiries, carried out for NHS London, the body which oversees healthservices in the capital, blamed system failures instead of individualsfor the mistakes.
However, they acknowledge he was a difficultcase because he could go through long periods without showing any signsof overt mental illness.
Bryan was first sent to Rampton secure hospital after beating20-year-old shop assistant Nisha Sheth to death with a hammer in 1993.
In 2002 he was released into the community after applying to amental health tribunal and allowed to live as a care in the communityout-patient.
He was sent to a hostel where residents have their own front door and room key.
Butafter an allegation of an indecent assault on a 17-year-old girl, Bryanwas sent back to hospital, but this time he was only an informalpatient on an open ward at Newham General Hospital in east London.
InFebruary 2004, he walked out of the unit and killed his friend BrianCherry, 45, before frying and eating parts of his brain. He had alsostarted to dismember the body.