An independent inquiry criticised health officials yesterday over the treatment of a paranoid schizophrenic who killed two people and injured three others after he was mistakenly released from hospital.

Wayne Hutchinson shot a man dead and fatally stabbed a woman during six days of random violence in Brixton, south London, in late 1994.

The inquiry found that Hutchinson's illness had started in August 1994. He had complained of hearing voices, but despite increasingly violent behaviour, a junior doctor gave him home leave.

The report, released by Lambeth, Southwark and Lewisham health authority, found that health professionals made errors which resulted in Hutchinson, now 27, being allowed out of South Western Hospital, Brixton. The hospital, which no longer exists, was criticised for not putting Hutchinson in a locked ward. It found the danger he posed to the public, combined with his mental state and his use of drugs, was under-played by doctors.

The chairman of the panel, Kieran Coonan QC, said: "We thought this was very poor indeed both from a nursing side and the medical side but one cannot ignore the difficulties and also the fundamental lack of resources of beds."

The report made 32 recommendations to tighten procedures and communication between health bodies.

The families of the two victims, Anthony Kelman and Margaret Hatton, said in a statement that there had been a catalogue of errors: "We find it extremely difficult to understand why Wayne Hutchinson was not taken into care."

The family of Mr Hutchinson, who is now detained in Broadmoor Hospital, said: "We hope and pray there will be no further incidences of a locum making a wrong decision that affects the lives of innocent people."

Martin Roberts, the health authority's chief executive, said it was clear there had been "systematic failures".