A triple murderer was allowed out of a psychiatric hospital despite a doctor's report that he posed a risk to women.
Hardy was released from hospital by its managers
Anthony Hardy, from Camden, north London was jailed in 2003 for the killings of Sally White, Elizabeth Valad and Bridgette MacClennan.
He was released by a mental health panel in 2002 - six weeks before he killed two of his victims.
But an inquiry found he was not mentally ill and could not legally be held in hospital.
Sally White's body was discovered by a neighbour at Hardy's flat in January 2002 - 10 months before her killer was placed in hospital - but her death was put down to natural causes.
Sadistic and manipulative
Hardy was sent to St Luke's Hospital in Muswell Hill, north London, after he came to the authorities' attention during a dispute with the neighbour.
One month after his release from hospital he lured Miss MacClennan and Miss Valad to his flat and murdered them.
He was arrested after their dismembered remains were found in bin bags near his home.
The report said Hardy was sadistic and manipulative with a history of violence and his doctors felt unease at his difficult personality.
The panel at St Luke's did not receive a forensic report from a psychiatrist which said he posed a risk to women. He had previously assaulted his wife when in Australia.
Mr Hardy's mental state was "clinically normal" at the time of the killings
Hardy co-operated with his care plan and the community care team "managed his care very effectively"
The decision by the hospital managers to release was appropriate "under the prevailing circumstances"
Specialist expert who gave evidence on mental health issues, Professor Tony Maden, said Hardy "was untreatable"
Detention under the Mental Health Act was not justified because Hardy showed no mental state abnormalities
But the inquiry into the deaths by the North Central London Health Authority, said it would not have made a difference to the panel's decision as he had been successfully treated for his manic depression and drinking problems.
This means that under he Mental Health Act the hospital had no legal right to hold him.
Jonathan Street, spokesman for the Camden and Islington Mental Health Trust, said in such cases a patient's details are now sent on to the Multi-Agency Protection Panel (MAPP), which monitors them to protect the public.
But back in 2002 the guidelines took into account patient confidentiality and Hardy's details were not passed on to MAPP.
"The guidelines for how we deal with MAPP have been tightened up since 2002," Mr Street said.
"We need to find a balance. If patients knew we could report them to police they may not be willing to be treated.
"You need to remember that not all mentally ill people are dangerous, and not all dangerous people are mentally ill."
Erville Millar, Chief Executive of the trust, told BBC News: "Mental health services should be allowed to get on with treating the mentally ill and it is up to the criminal justice system and politicians to deal with those who are dangerous or who pose a risk.
"These crimes appear to be sexually motivated and mental illness played no part in them."
Robert Robinson, the solicitor chairing the inquiry, agreed saying: "It remains true that the vast majority of murders are not associated with mental illness.
"In this case, having carefully reviewed the evidence, we have concluded that Mr Hardy's illness was purely coincidental to the three murders."