In a devastating inquiry report into a knifeman’s stabbing spree in Birmingham, one man tragically lost his life and seven others were injured. The independent investigation commissioned by the NHS revealed a series of “missed opportunities” to recognize the risk surrounding the perpetrator, Zephaniah McLeod, a paranoid schizophrenic. The report criticized the supervision provided to McLeod and highlighted the lack of understanding of his mental health condition, ultimately leading to the tragic events of September 2020.

Zephaniah McLeod, a 27-year-old with a history of convictions, was released from HMP Parc in South Wales without planned contact with statutory services five months prior to the attacks. The inquiry report outlined four missed opportunities to comprehensively assess McLeod’s mental health and make adequate arrangements for his release.

McLeod carried out three stabbings in Birmingham’s city centre before returning home, re-arming himself, and continuing his rampage. Jacob Billington, 23, tragically lost his life, while his friend Michael Callaghan sustained life-changing injuries. Subsequently, McLeod was sentenced to life imprisonment with a minimum term of 21 years after admitting to manslaughter, attempted murder, and wounding charges.

The families of Jacob Billington and Michael Callaghan provided impact statements criticising multiple government agencies’ actions and highlighting the failings and incompetence detailed in the report. Jo Billington, Jacob’s mother, expressed her heartbreak and disappointment in the agencies’ awareness of the risk posed by McLeod. The sentencing judge also criticized the level of care and monitoring given to McLeod prior to the attacks.

The report condemned the Mental Health In Reach teams for their inadequate understanding and treatment of McLeod’s known mental health conditions while he was in prison. Several crucial findings were highlighted, including the lack of continuity in his mental health treatment, the failure to review historical assessment information, and the team’s failure to follow up on missed appointments.

Additionally, the report noted a lack of professional curiosity and understanding of McLeod’s mental health needs, insufficient consideration of his behaviours in the context of his conditions, and missed opportunities to refer him to secure mental health units while in prison.

The report presented a series of recommendations aimed at rectifying the shortcomings identified in the supervision of McLeod. These recommendations included improving services, developing an operational policy for prison discharge services, and ensuring the mental health in-reach team at HMP Parc has sufficient resources. The report also called for a serious case review by the West Midlands MAPPA Strategic Management Board.

The director of the Hundred Families charity, Julian Hendy, expressed his shock at the report’s findings and criticized the agencies’ failure to effectively monitor a dangerous and unwell individual. Birmingham and Solihull Mental Health Foundation Trust acknowledged the need to review their discharge service and expressed their sympathies to the grieving families.