In September 2020, a series of stabbings took place in Birmingham city centre during which a man died and six others were seriously injured. In 2021, Zephaniah McLeod was sentenced to 21yrs in prison, but also made subject to a hybrid order under s45A of the Mental Health Act 1983 which means he was taken first to Ashworth High Secure hospital. You can read more about these awful attacks and hybrid orders in my original post, written at the point of sentencing.
Today, the His Majesty’s Senior Coroner for Birmingham and Solihull concluded a two-week inquest in to the death of the man who died, Jacob Billington, 23. She will be issuing a Preventing Future Deaths (PFD) report in due course, because of serious concerns about the lack of planning, communication and follow up on the offender after he was released from prison for firearms and drug offences.
LESSONS LEARNED
As ever, we hear the phrase lessons learned, albeit in the media coverage of this inquest, I haven’t heard it from HM Prison or HM Probation service. The Coroner herself is quoted as saying “I hope lessons can be learned” and Mr Billington’s mother, Joanne, is quoted as saying she has no reason to think lessons have been learned. Last year, well before the inquest, NHS England published an independent homicide review in to the care of Mr McLeod. You can read it for yourself but Mrs Billington’s concern was recommendations were vague and as the inquest concludes, she has repeated her doubt learning.
Read the materials linked on this post and it’s hard to disagree.
The major criticism within the report and the inquest, for which presumably we will see detail when the PFD notice is published in due course, was about communication, planning and effective risk assessment upon Mr McLeod’s release from Parc Prison in South Wales. During his previous sentence had moved about the prison system a number of times, but it was from Parc that he was released to no particular address and this is not the first killing to have occurred shortly after the release of a Parc prisoner – Matthew Williams, Gareth Wyn Jones and Leyton Williams all did likewise in concerning circumstances. McLeod had been diagnosed with schizophrenia in 2012 and prescribed medication for this – he had declined to take medication both within and without prison. (You can’t be forced to take medication in prison and the MHA can’t be used on prisoners.) He had stated he was going to go to North Wales after release, but ultimately went to Birmingham.
His release from prison should have been subject to proper planning, and for a range of reasons: there should be planning for all prisoners about their post-release address, not least because most prisoners will be subject to Probation service oversight so they’ll need to know where the person lives and which Probation office to inform to undertake that work. In this particular case, the type of offending involved – guns and drugs – means there should be multi-agency public protection arrangements (known as MAPPA); and of course the fact Mr McLeod had a long-standing diagnosis of schizophrenia and was prescribed treatment whilst in prison, means there should have been post-release healthcare planning.
All of this is hard to do if it’s not known where he will be living and no-one follows it up.
MAPPA
Multi-agency protection arrangements are a whole thing on their own — it means the MAPPA coordinator for area where someone will live should be informed so new cases can be risk-assessed to determine wat ‘level’ they will be monitored – one, two or three.
Level one basically means probation service will do what they must whilst the person remains on licence (if there is one) and the police will oversee someone through their ‘offender managers’, with a yearly or six monthly visit. Level two means active multi-agency management and level three just means multi-agency active management on stilts, with more monitoring because of higher potential risks and consequences if the person re-offends.
But new cases needing to be risk-assessed for whether they start at levels one, two or three can only be so assessed if the MAPPA coordinators is informed and that means we need to know where the person will be living. Often such risk assessment occurs before release, once the agencies know when someone will arrive (back) in their area so planning for these things should be done ahead of release.
This didn’t really happen in Mr McLeod’s case and whilst he was initially considered suitable for level two monitoring, it quickly moved to level one and HM Coroner was left bemused by that, it seems and it will be a feature of the PFD along with the concern about management of mental health care.
SIMILARITIES
Mrs Billington made mention in her comments after the inquest about similarities in this case with that more recent tragic events in Nottingham – we can see why. Random attacks with a knife, mentally ill offender, both of whom have ended up in Ashworth hospital albeit under different types of MHA order. In fairness, though, the families of the Nottingham victims asked the Attorney General to review the offender’s sentence and their comments suggested they think he should be on the kind of ‘hybrid order’ Mr McLeod is on – we await the decision of the Court of Appeal on that one.
I must admit to thinking of other cases before I thought about Nottingham, becuase of the similarities of the failings, rather than the similarity of the incidents —
Nicola Edgington was convicted of manslaughter on the grounds of diminished responsibility (DR) in 2006 after killing her own mother. Just three years later she was deemed fit for discharge from hospital and she moved to Greenwich. There was also a failure to ensure MAPPA processes were followed and her mental health care by a community team in Greenwich wasn’t where it needed to be. Eighteen months after discharge, when the head of MAPPA for Greenwich still didn’t know she was living in the area and in need of MAPPA oversight, Nicola killed Sally Hodkin and attempted to kill Kerry Clark in south London. She was subsequently convicted of murder and attempted murder and imprisoned, but then transferred to Rampton hospital – I’m told she has since been returned to prison.
Philip Simelane shocked the city of Birmingham and the country by killing a teenager on her way to school, Christina Edkins. This one also struck me specifically because it happened on the number 9 bus on the Hagley Road in Birmingham – a bus I’ve taken many times as a student and a young police officer and the attack happened on the area I policed as a PC. Simelane was also convicted of manslaughter (DR) and detained in a mental health hospital but the background failure here was a prison service release where he was given a little money, some psychiatric medication and released without any proper accommodation. He was thought to have lived rough and bounced around the transport network in the days after release and until he killed Christina, whose death was deemed preventable by the care review undertaken afterwards.
LESSONS LEARNED
This must be why the standard press releases from organisations about lessons learned stretch the patience of families who have lost loved ones to tragedies. It’s just too easy to go back to other, previous cases where we see similar failings followed by a promise to learn lessons. Jacob’s tragic death show that lessons which should have been learned after Sally Hodkin’s death and after Christina Edkins’s death haven’t really been learned – at least not nationally.
In some cases, I’m still slightly prepared to believe in just some cases that areas who have experienced a contentious tragedy put right their systems and processes. But is that replicated nationally across similar agencies? In other words, does Agency A in area X and area Y learn the lessons of tragedies which occurred to Agency A in area Z? Not always – this website has been making that point in light of real examples in policing for a number of years. The only difference in this post is the failures sitting elsewhere in the criminal justice system, with HM Prisons and HM Probation services.
Can’t help but think Inquest’s call for a National Oversight Mechanism in their No More Deaths campaign to address these kinds of problems is the right one because too many mistakes are repeated and as Inquests’ Director Deborah Coles said (and I’ll never tire of quoting this), “Not just guilty of failing to learn lessons, but repeatedly guilty of failing to learn repeated lessons.”
Winner of the President’s Medal, the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All opinions expressed are my own – they do not represent the views of any organisation. (c) Michael Brown, 2024
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
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