By Nick Triggle
Health reporter, BBC News
Peter Bryan has killed three people
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".
The report into Mr Cherry's killing criticised the speed at which Bryan was moved into the community.
He spent only six months in a specialist centre designed to get him used to independent living following his time at the secure hospital and before his move to the hostel. The normal length of time is up to two years.
The experts also said the staff - a psychiatrist and social worker - detailed to look after him in the community did not have the necessary experience.
PETER BRYAN TIMELINE
March 1993 - Kills 20-year-old shop assistant Nisha Sheth in a hammer attack and then sent to Rampton secure hospital
July 2001 - Transferred to a hostel to prepare for life in the community after mental health tribunal agrees to his release
February 2002 - Moves into a nine-bed hostel for people with mental illness, becoming a care in the community patient
February 2004 - Accused of sexual assault against 17-year-old girl and subsequently moved into an open ward at a mental health unit
February 2004 - Walks out of the unit and kills Brian Cherry before eating part of his brain
April 2004 - Attacks fellow Broadmoor patient 10 days after arrival at top security hospital. The man later dies from his head injuries sustained in the attack
March 2005 - Given a life sentence by court judge for the killings
This in turn led to a reduction in his anti-psychotic medicine, they added.
And the health service was criticised for not taking seriously enough the allegation of sexual assault.
Bryan was only moved to Newham for his own protection as the family and friends of the girl were threatening him.
The investigators said a move to a secure unit could have stopped him killing Mr Cherry.
However, they did acknowledge Home Office rules may not have allowed his recall - something which they said needed to be looked at - and his actions could not have been predicted.
The management at Broadmoor also came under attack for the standards of monitoring, risk assessment and anti-bullying procedures.
Between being admitted and his attack on Mr Loudwell, Bryan was never once medically examined and no plan was drawn up to protect other patients.
Mr Loudwell, who had complained of being bullied - he was in Broadmoor for a sexual attack and killing of a pensioner - was attacked in the dining room, which was not being monitored by staff at the time.
Jane Mishcon, chairman of the inquiry into Mr Cherry's killing, said: "There are lessons here for the whole of the NHS."
And shadow health minister Anne Milton said the public had been "let down".
"Mental health trusts and the criminal justice system need to look very carefully at this report to learn from the grave errors made, to prevent other horrifying, yet preventable, incidents like this from happening in the future."
The two NHS trusts in charge of his treatment at the time of his killings apologised for the failings and said improvements had been made.
Peter Cubbon, chief executive of the West London Mental health Trust, which is responsible for Broadmoor, said CCTV had been introduced and staff given better training.
And Dr Robert Dolan, of the East London NHS Trust, which was in charge of the services when Bryan killed Mr Cherry, added: "The trust has established new systems to ensure that patients with a history of violence are under the care of staff with sufficient experience and training to look after them."