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A serious of egregious errors
resulted in the deaths of two people, after medical staff released a
mentally ill convicted killer from the mental health center where he was
living.
Peter Bryan, a schizophrenic,
cannibal and convicted murderer was released from the medium-security
Riverside House to a hostel where he was free to come and go, according
to an article in the British paper, the Telegraph.
Merely three hours after his
discharge from the facility in 2004, he killed Brian Cherry, a friend,
and cooked part of his brain, the paper stated.
After that murder, Bryan was
sent to Broadmore secure hospital, where not even 10 days later he
attacked and killed Richard Loudwell, a fellow patient.
Two inquiries into Bryan's case
faulted National Health Service managers for leaving the now 39-year-old
killer in the care of a social worker with no mental health training and
who was in over his head dealing with a notoriously manipulative patient,
according to the London Evening Standard.
However, the reports noted that
the nature of his condition meant that Bryan was incredibly manipulative,
and able to appear normal even as his mental health was incredibly
deteriorated.
The reports "outlined a
catalogue of errors" according to the Telegraph, in the treatment of
Bryan following his 1993 murder of Nisha Sheth, a shop assistant whom he
beat to death with a hammer.
Brain-eating killer claimed
two more victims because of 'systematic' NHS failures
CailyMail.co.uk
03rd September 2009
A 'systematic failure' in the
treatment of a schizophrenic allowed him to murder a friend and eat
parts of his brain before he went on to kill a fellow patient in
Broadmoor, two separate reports have revealed.
Convicted killer Peter Bryan was
given permission to live in a hostel in north London where he could come
and go as he pleased.
He had been admitted to a secure
hospital after beating shop assistant Nisha Sheth to death with a hammer
in 1993.
But eight years later, mental
health experts decided he could live in the community under supervision.
In 2002 he moved to the hostel
and at the beginning of 2004 social workers applied for his transfer to
'low support accommodation' but four weeks later Bryan murdered his
friend Brian Cherry, 43, and cooked and ate his flesh.
In a damning report into the
case, authors found that while living in the community Bryan was looked
after by an inexperienced social worker and a psychiatrist who had never
worked with a convicted killer.
The report found 'there was,
however, a systemic failure to ensure that the key professionals
allocated to care for Peter Bryan in the community had the necessary
experience to deal with someone with his forensic history and complex
presentation.
'The two professionals, who were
a supervising psychiatrist and social supervisor, for this unusual and
complicated patient were a general adult psychiatrist who never before
had had responsibility for a patient who had killed someone, and a very
inexperienced social worker who had no training in mental health.'
Following the killing, Bryan was
sent to Broadmoor but within two months killed fellow patient Richard
Loudwell, 59.
The report outlined a catalogue
of errors in the way East London NHS Foundation Trust dealt with Bryan.
A psychiatrist and social worker
assigned to him should never have been given the responsibility for
taking care of Bryan while he was in the community, it concluded.
He was transferred to the medium
secure ward of the John Howard Centre in Hackney, north east London,
after spending seven-and-a-half years in a high secure unit at Rampton
Hospital.
It was typical that a patient in
his condition would spend around two years at such a centre.
But after just six months he was
transferred as a secured patient to a forensic hostel - Riverside House
in north London.
It was there that an 'inexperienced'
social worker was appointed to look after him.
The report found he had been a
general social worker for only five months.
The panel said: 'He had no
training in mental health and no experience as a social worker working
with psychiatric patients, let alone mentally disordered offenders.'
The social worker was not 'an
appropriate choice' to care for Bryan, the report found.
A supervising psychiatrist
assigned to him at this stage was also found to have never had
responsibility for someone who had committed murder.
This led to a 'lack of effective
management of Bryan in the community'.
The report also criticised the
decision to reduce the dosage of medication Bryan was receiving at the
hostel after he complained to staff.
This reduction could have been a
factor in the eventual deterioration of his mental health, the report
found.
This led in 2003 to Bryan being
placed in a position where he was allowed to self-medicate.
The trust was also criticised
after it emerged that it had not acted swiftly enough after an
allegation that he indecently assaulted a 17-year-old girl.
The report said it was 'seriously
concerned' that despite the allegation, no attempt was made by the
hostel or his social worker to contact the Home Office at the earliest
possible opportunity.
Following the alleged indecent
assault, Bryan was moved 'for his own safety' from the hostel after
being threatened by the girl's family.
He was temporarily placed on a
psychiatric ward at the Newham Centre in London in early February 2004
but just two weeks later Bryan was given permission to leave the ward
temporarily.
He went straight to a DIY shop
where he bought a claw hammer, Stanley knife and a screwdriver and then
went to kill Brian Cherry.
Police were called to Cherry's
flat to discover a semi-naked Bryan brandishing a carving knife and
covered in dried blood.
Both of Cherry's arms and one of
his legs had been severed from his body.
In the kitchen parts of Cherry's
flesh were found cooking in a frying pan.
Bryan told police following his
arrest: 'I ate his brains with butter. It was really nice.'
He was sent to Broadmoor but
shortly after his arrival he struck again, killing Loudwell.
A second report released today
criticised West London Mental Health NHS Trust for failures in the case.
Loudwell died after sustaining
serious head injuries in the attack, which took place in the dining room
of the ward.
No staff were present in the
dining room at the time.
The report said Bryan had been
intending to kill Loudwell for some time prior to the attack.
Loudwell complained that he was
being bullied by other patients, but his pleas to staff were ignored,
the report found.
'Bullying was not treated
sufficiently seriously by any member of the clinical team, nor was it
given the priority it merited in Loudwell's case.'
The report criticised the Trust
for not carrying out a risk assessment on Bryan before he attacked
Loudwell.
The report stated: 'Had a risk
assessment been carried out properly, then it is likely that Peter Bryan
would have been recognised as highly dangerous.'
The report found that it was 'not
appropriate' that patients on the ward were allowed out of the sight of
staff.
The health trusts involved
apologised for failures in the handling of the case but revealed that
nobody had been disciplined as a result.
Bryan was able to function in
such a way that made it difficult for even experienced health
professionals to detect just how dangerous he was, the reports found.
Dr Robert Dolan, chief executive
of East London NHS Foundation Trust, said: 'We offer our deepest and
most sincere condolences to everyone affected by this case.
'Peter Bryan clearly had a very
severe and complex mental illness. In his lengthy contact with a range
of services and a range of professionals, he was able to function at a
high social level and did not display any of the typical behaviour or
symptoms one would associate with a severe mental illness.
'We accept that elements of the
care provided to Mr Bryan could have been better but we also note that
the independent report does not say the killing of Mr Cherry could have
been predicted.'
He said an action plan had been
implemented following the case to improve the trust's quality of care.
Peter Cubbon, chief executive of
West London Mental Health NHS Trust, apologised to Mr Loudwell's family.
He said: 'He was a patient in
our care and we failed to ensure his safety.
'We also failed Peter Bryan and
our apology is unequivocal.'
Following Mr Loudwell's death,
the Trust has reduced the number of patients on the ward where the
killing took place.
There are now also increased
numbers of qualified nurses working on the ward and more patient
observation.
Asked about the Bryan case,
health minister Mike O'Brien told BBC Radio 4's World at One: 'This is
something that raises some very worrying issues and we want to be sure
we look at this with a great deal of care.
'If changes are necessary they
will be made.'
Shadow Health Minister Anne
Milton said: 'This shocking report shows a complete failure of mental
health and social services to protect both the public and a very sick
mentally ill man.
'It appears that there were
repeated mistakes that ended in tragic consequences for the victims and
their families and our sympathy is with them having to face the loss of
a relative in such horrific circumstances.
'Everyone has been let down and
we need to make sure that systems are in place to ensure that mentally
ill people who are such a risk to the public are in specialist secure
care, not wandering our streets.'
Barbara Young, chairman of the
Care Quality Commission, added: 'This is a disturbing and tragic story.
'Providing healthcare to this
group of patients requires a high degree of skill and expertise.
'But this report clearly
illustrates just how badly things can go wrong when secure institutions
have poor safeguards in place to protect people.
'We have already taken action at
Broadmoor. Our recent investigation identified a series of problems and
proposed significant improvements that will make the service safer. We
have been encouraged by the response.'
Loudwell's family hit out over
the way they have been treated. His sister, who is not named, said: 'The
terrible feelings that this family experienced from when we initially
learned of the attack on Richard have turned to anger and cynicism.'
She said the family have never
forgotten that another family are still suffering from Loudwell's own
actions after he killed pensioner Joan Smythe in 2002, but 'expected
that people would be kept safe from Richard, and that he would be kept
safe from others' once inside Broadmoor.
His family said he called his
mother from the ward the day before he was attacked to say he feared for
his life and was being bullied.
A family spokeswoman said they
were 'truly unprepared for the shocking scale and catalogue of failings
at all levels and in all disciplines of staff at Broadmoor which
contributed to Richard's death'.
She said family members were 'horrified'
when they were given details of what happened to Loudwell in March 2009.
In a statement, Loudwell's
sister condemned 'the way that we have been treated by the trust, the
long delay in the trust accepting or apologising for the collective
failings that led to Richard's death, and the apparent persistent
failure of the trust to learn the lessons from their failure to keep
Richard safe'.
Kate Maynard, the family's
solicitor, added they had been left with the 'difficult decision' of
whether to try to represent themselves at an upcoming inquest into
Loudwell's death or 'invest their life savings in legal costs'.
'This state of affairs is deeply
unjust,' she said.
Peter Bryan: The
Real Hannibal Lecter
By Peter Stubley
Cannibal Peter Bryan found his 'appetite
for killing' after he battered a young woman to death in a fashionable
Kings Road boutique.
He had fallen for Nisha Sheth,
the 20-year-old daughter of the shop's owners, while working as a shop
assistant but was sacked after being caught stealing clothes.
A week later on March 18 1993,
Bryan, then aged 23 and living in Derby Street, Forest Gate, East London,
returned to get his revenge.
He knocked Nisha's 12 year-old
brother Bobby to the floor and battered her over the head with a claw
hammer as she chatted on the phone. Nisha was dead before the ambulance
arrived.
An hour later Bryan, high on
cannabis, jumped from the third floor balcony of a building in Battersea
in an apparent suicide attempt. He survived and admitted the
manslaughter of Nisha on the grounds of diminished responsibility.
He was locked up in the Rampton
maximum security psychiatric unit 'without limit of time' but was
released on the advice of psychiatrists nine years later.
Bryan now had the chilling
ability to mask his madness under a veneer of normality.
A short stay at the Riverside
House residential care home in Seven Sisters, north London, ended when
he was caught 'blowing raspberries' on a 16-year-old girl's stomach.
He was then treated as a care in
the community patient at Topaz Ward in Newham General Hospital but on
February 17, 2004, it was agreed Bryan could leave the ward as much as
he wanted. By 7pm that night he had killed his second victim Brian
Cherry and begun to dismember the body.
'I ATE HIS BRAIN WITH BUTTER'
Mr Cherry, 43, who was described
as a 'nice man, lonely with no friends' lived at a ground floor flat at
1 Manning House, The Drive, Walthamstow, east London.
At around 7.15pm his friend
Nicola Newman let herself into the flat at around 7.15pm and noticed a
strong smell of disinfectant.
Bryan then emerged from the
living room bare-chested and holding a knife to announce: 'Brian is dead.'
'She naturally did not believe
him and tried to look into the room,' prosecutor Aftab Jafferjee told
the Old Bailey.
'She saw Mr Cherry lying naked
on the floor and could see one of his arms on the floor clearly
separated from the rest of his body.'
The police arrived to find Bryan
standing in the hallway in the dark with bloodstained hands, jeans and
trainers.
In the kitchen officers noticed
a small amount of meat in a frying pan next to an open tub of Clover
butter.
The meat was part of Mr Cherry's
brain. More brain tissue and hair matted with blood was heaped on a
plate next to a knife and fork on the draining board.
Bryan told officers he had
killed Mr Cherry after the victim opened his door and then said: 'I ate
his brain with butter, it was really nice.'
He later added: 'I would have
done someone else if you hadn't come along. I wanted their souls.'
SKULL SMASHED OPEN
Mr Cherry's skull had been
smashed open with at least 24 blows from the hammer and his head had
been partly sawn off.
Bryan had also had hacked off
his right leg and both arms. Blood was spattered around the living room
and three blood-stained knives were strewn around the floor.
MrJafferjee said: 'The severed
left leg was partly sawn and partly fractured. At the top of the right
left the muscle had been completely divided and superficial sawing of
the bone had commenced.
'The pathologist concluded the
defendant had been interrupted before he could complete the amputation
of that limb.'
Bryan later admitted that he was
'comforted by the smell of blood' and added: 'I used the Stanley knife
to cut them off and some other kitchen knives but I had to stamp on them
to break the bone.'
Even at Pentonville jail he told
a member of staff he wanted to kill a warder and eat someone's nose and
prison officers had to use riot shields when unlocking his cell in case
of attack.
Bryan was finally admitted to
Broadmoor maximum security hospital on April 15, 2004, and kept in a
cell. But yet another blunder meant doctors believed he had 'settled'
and could be transferred to a medium risk ward.
'There was a significant failure
within the Mental Health care regime in recognising the danger that the
defendant presented,' said Mr Jafferjee.
'Even more startling is the fact
that such a capacity for failure within this regime was to manifest
itself again in just a few weeks time.'
'I WANTED TO EAT HIM - BUT I
DIDN'T HAVE THE TIME'
Third victim, Richard Loudwell,
60, was awaiting trial for the murder of an 82-year-old woman and was a
patient on the same ward.
On the day of his death, April
25, 2004, Mr Loudwell was 'happy, cheering and laughing.' But at around
6.10pm three members of staff heard two bangs coming from the dining
room and found Mr Loudwell lying on the floor next to a table and chair.
His face was covered in blood
and there was a strangulation mark around his neck. He died on June 5
from broncho-pneumonia caused by severe brain injuries.
When Bryan was found he admitted
he had tried to strangle Mr Loudwell with a piece of cord and smashed
his head on the floor.
Bryan told doctors: 'I get these
urges you see. I've had these urges ever since I saw him. He's the
bottom of the food chain, old and haggard. He looked like he'd had his
innings.
'I was just waiting for my
chance to get at him. I wanted to kill him and eat him. I didn't have
much time. If I did I'd have tried to cook him and eat him.'
Asked if wanting to eat people
was normal, he replied: 'Of course it's normal. Cannibalism is normal.
It's been here for centuries. If
I was on the street I'd go for someone bigger, you know, for the
challenge.
'I felt excited when I attacked
him. I wanted to shag him when he was alive and also when he was dead.
'I wanted to cook him but there
was no time, nor was there access to cooking equipment. I briefly
considered eating him raw.'
He named another patient as his
next target and added: 'It's something like a ritual. I must be becoming
a serial something.'
Mr Jafferjee said: 'He believed
that the human body was a natural food source and it made him stronger.
He had wanted to kill eight people because he wanted to be known as a
serial killer.'
Bryan even told the doctors he
thought he would be released into the community again despite killing
three people.
THE PYSCHO WHO CAN APPEAR NORMAL
Psychiatrist Dr Martin Lock, who
carried out a series of 'Silence of the Lambs' style interviews with
Bryan said he was 'the most dangerous man I have ever assessed.'
He told the doctor: 'You look
like a brainy chap and you are quite slim. I think I could take you.'
Bryan also described the
victim's arms and leg as 'tasting like chicken.'
MrJafferjee said Bryan should
die behind bars and added: 'He is at his most deadly when he is able to
present himself as entirely calm and settled.
'This case reveals a chilling
insight into the mind of a man who had developed an appetite for killing.'
Bryan was given a whole life
sentence and will never be released from Broadmoor again.
Judge Giles Forrester told Bryan:
'You had the urge not only to kill but also to eat the flesh of your
victims.
'You experienced feelings of
power and invincibility. Not only that but you gained sexual excitement
from the act of battering your victims to death.
'The earlier treatment at
hospital did not cure your disease and there is no reason to believe a
hospital order now will do what it failed to achieve back in 1994.
'It is clear that you can appear
calm and cooperative while harbouring bizarre psychotic beliefs.'