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Published 7 September 2009, doi:10.1136/bmj.b3648
Cite this as: BMJ 2009;339:b3648
Clare Dyer
1 BMJ
| The first 150 words of the full text of this article appear below. |
A "systemic failure" allowed Peter Bryan, a dangerous, mentally ill killer who went on to kill two more people, to be supervised in the community by an inexperienced psychiatrist and social worker, an independent inquiry has concluded.
Mr Bryan, who has schizophrenia and has since been given a diagnosis of a personality disorder, killed an acquaintance, Brian Cherry, in 2004 and then fried and ate part of his brain. Ten days after he had been detained in Broadmoor high security hospital for the killing, he attacked a fellow inmate, Richard Loudwell, who later died of his injuries.
The reports of two separate inquiries into the two incidents, carried out for the strategic health authority NHS London, found a catalogue of failings in Mr Bryans care and supervision. But they point out that he was a highly unusual patient who appeared normal even when he was seriously mentally ill.
The inquiry
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