Reports into two killings by a man with schizophrenia have sparked calls for better sharing of information in management of mental health patients.
Peter Bryan killed a friend, Brian Cherry, and ate parts of his brain, in 2004, two years after release from a secure hospital for a previous killing.
Later in 2004 Mr Bryan fatally attacked fellow patient Richard Loudwell at Broadmoor high security hospital.
NHS London commissioned independent inquiries into the care Mr Bryan received from the two trusts responsible for his treatment, East London Foundation Trust and West London Mental Health Trust. Their findings were published last week.
Responding to the findings, NHS London said lessons for the whole NHS included the need for only professionals with enough experience and training to have responsibility for patients, and the need for better communication between all agencies.
NHS London chief nurse Trish Morris-Thompson said: “East London Foundation Trust has agreed a joint action plan with Newham Primary Care Trust and its local authority.”