Clinical Negligence & Catastrophic Injury Solicitors
Birmingham stabbings killer released from prison unsupervised.
A mentally ill man who went on a fatal stabbing spree in Birmingham had been released from prison unsupervised, a review found.
Paranoid schizophrenic, Zephaniah McLeod, killed Jacob Billington, 23, and hurt seven others in five separate attacks.
Mr Billington's mother said a multi-agency NHS-commissioned review into McLeod's treatment showed a catalogue of "astonishing failings and incompetence" and that the report into what led to the stabbings on 6 September 2020 made "very weak" recommendations that failed to get to the heart of what went wrong.
The review and report was carried out by Niche Health and Social Care Consulting, an independent management consultancy specialising in supporting health care providers with safety, governance, and quality and carries out independent investigations following very serious incidents.
Jo Bilington added: "There appear to be no consequences at all for the agencies involved and I am not satisfied that the failings identified in this report will not continue.
"All the agencies knew about the offender. They knew he was dangerous and violent; that he didn't comply with medication and he had made multiple threats to hurt people. In the end, he carried out those threats. Eight innocent people have had their lives changed forever."
Her son, a Sheffield Hallam university librarian, from Crosby, Merseyside, had been enjoying a night out with friends when he was attacked and his lifelong friend, Michael Callaghan, who was gravely injured, would suffer "the horrendous consequences of his injuries for the rest of his life.”
McLeod, 27, of Birmingham, was detained for at least 21 years in November 2021 after admitting manslaughter, four counts of attempted murder and three counts of wounding.
McLeod, who has already caused trouble in Birmingham city centre, stabbed Jacob Billington and Michael Callaghan in their neck and Jacob died at the scene. Michael went on to have a "catastrophic" stroke and was left completely paralysed down his left-hand side.
Michael Callaghan’s mother, Anne, added: "This investigation has identified a woeful lack of communication, with uninformed and reckless decision-making regarding MAPPA (multi-agency public protection arrangements) and the management of McLeod during his time in, and release from, prison."
McLeod had a long history of offending, starting in his teens, which the report said included robberies, threats and carrying a knife but the review found that he had not been "appropriately treated and medicated" for nine years prior to the attacks.
Five months before the attacks, he was released unsupervised from HMP Parc, Bridgend, Wales, to no fixed abode, after serving three years for drug and firearms offences. The report said that support services "did not know where he had gone." He claimed he was going to North Wales, but returned to Birmingham.
Regularly moved between prisons, there was "no continuity in the assessment of his mental health and his care", and he failed to engage with mental health services in prison or the community and was reluctant to take prescribed medication.
There was also no evidence" he "made any attempt" to address his mental health problems or criminal behaviour.
The report said that Mental Health Inreach Teams (MHITs) in prisons were not assertive in monitoring and supporting his compliance with taking medication for his mental health problems. It adds that his prison behaviour included sharpening a toilet brush handle "to a point", but prison teams did not seem to link this to his mental health.
In particular, the review identified "four missed opportunities" for services to gain a better understanding of his "mental health needs and his risk, and allow for a planned release from prison at the end of his sentence.”
In August 2019 mental health teams at HMP Stoke Heath, Shropshire, considered referring him to medium secure mental health services but did not as they said he was compliant with his medication although the report said that this was only for five days.
He was removed from multi-agency public protection arrangements (MAPPA) in October 2019, due to not engaging with any of the services, which resulted in him remaining in prison until his sentence ended and not being supervised by police or probation services afterwards.
The report added: "Furthermore, his observed mental health symptoms were not considered to be of a degree to reach the threshold for assessment or detention under the Mental Health Act."
After being referred by his GP to a community mental health team he was visited at home on 3 September and was encouraged to meet the team consultant psychiatrist that afternoon but told the psychiatrist over the phone he had no money to go. He said he was willing to attend an appointment the following week but three days later carried out the five Birmingham attacks.
Niche's associate lead for mental health investigations who co-authored the report Nick Moor, said the case was "particularly complex" as it involved 14 different agencies organisations and crossed the NHS in both England and Wales.
He added: "Prisons are not the right place to treat people with serious mental illness, that's the hardest part of this case."
The report's recommendations include that the description of the Birmingham & Solihull Mental Health Foundation Trust's prison discharge service should be reviewed to clearly define its work and remit and that there should be guidance for MAPPA chairs to ensure discharge from multi-agency public protection arrangements should happen only when it involved full information from all services.