Series of blunders by trust

The mental health trust at the centre of the Peter Bryan case was severely criticised by inspectors for "complacency" regarding suicides, homicides and other serious incidents.

East London and the City Mental Health Trust is bracing itself for more criticism after the court heard of a series of mistakes in the case.

Bryan was admitted to a mental health hospital only 10 days before killing Brian Cherry but was not sectioned under the Mental Health Act.

Over two years ago - a year before Bryan absconded and killed - the then health watchdog, the Commission for Health Improvement, produced a damning report on the trust. It had concerns over clinical risk assessment of patients, which will now come into question again.

The court heard Bryan was downgraded into less secure accommodation despite his failure to take medication, his drinking and violent behaviour.

In 2003 the commission reported: "There is a lack of processes and systems in place to provide effective risk management at all levels of the organisation and no direction from the trust board."

The commission found "an atmosphere of complacency within the trust" over "serious untoward incidents... resulting in a lack of urgency to investigate suicides, homicides and other serious incidents."