By Nick Triggle
Health reporter, BBC News
There are lessons for the NHS, the inquiry found
The Peter Bryan case could not be more gruesome.
He used a hammer to batter a man to death, before dismembering his body and cooking and eating part of his brain.
Two months later, in the spring of 2004, he attacked a fellow patient in Broadmoor hospital.
The case of the cannibal killer is clearly shocking.
But it has also once again opened up the debate about whether the public are getting enough protection from the mentally ill.
The Tories, for one, have accused the government of not doing enough to protect people and ensure dangerous individuals are locked up in secure hospitals.
Indeed, Bryan had spent seven years in a secure hospital before his release into the community.
The independent experts investigating the NHS handling of Bryan did not have an issue with this decision.
Patients have a right under law to ask an independent tribunal if they can be released.
Bryan asked for this and after being assessed - he had been taking his medication and doctors believed it was working and he no longer posed a threat to the public - it was agreed that he could leave Nottinghamshire's Rampton hospital.
However, what the inquiry did question was the standards in place in the care in the community team.
The staff assigned to Bryan were said to be not experienced enough, which meant their reaction to the warning sign - the alleged sexual attack - was not sufficient.
Instead of being sent back to a secure hospital he was moved to an open ward in a mental health unit - and this was only done for his protection after threats from the relatives and friends of the girl he was said to have attacked.
And this is where the investigators believe there should be firmer guidance from government, insisting those with serious problems be sent back to secure units in such circumstances unless there is a compelling reason not to.
But Dr Philip McGarry, of the Royal College of Psychiatrists, says community care had already changed since Bryan was being treated.
He says most areas now have specialist community forensic teams led by psychiatrists with training in dealing with mentally ill offenders.
"It is much better now. These teams can meet with patients on a daily basis and have a much better chance of stopping these kind of cases happening.
"Of course, no system can be perfect and there will probably always be tragic cases, but we can minimise the chances.
"The thing is we can't just lock people up indefinitely. Most will get better with treatment so it is only right that they are integrated back into society in a safe way."
However, what experts are agreed on is the risk of being killed - and indeed attacked - by a person with severe mental health problems is extremely low.
There are about 50 killings each year by people with schizophrenia - and on average just five of these are by complete strangers.
And while the 50 figure has risen slightly since the 1990s, research by the University of Manchester has found that the risk of being killed by someone with schizophrenia is about 1 in 20,000.
This compares to the 1 in 1,000 risk of being killed at all.
Dr McGarry says: "If we are talking about what is the biggest factor for homicide, alcohol and drug abuse is much more important than mental illness."
Marjorie Wallace, chief executive of the mental health charity Sane, agrees.
"Cases as chilling and gruesome as this are extremely rare and do a grave disservice to the majority of people with mental illness who are never violent.
"They set back every effort to combat stigma by decades."
Instead, she is more concerned that the failings identified in the NHS care Bryan received are acted up on.
"The inquiry report exposes the same blatant errors and serial misjudgements identified in more than 400 independent inquiries into homicides involving mental illness.
"We can only hope that the improvements announced today will make more of a difference than the many recommendations from previous inquiries."