Inquest rules systemic failures enabled fatal Birmingham knife rampage
23-year-old Jacob Billington from Merseyside was fatally stabbed by a paranoid schizophrenic in September 2020.
Last updated 8th Mar 2024
An inquest into the death of a young man who was stabbed to death in Birmingham has ruled he was unlawfully killed because of failures by authorities to manage his killer's release from prison.
23-year-old Jacob Billington from Merseyside "bled to death in the street" after being fatally wounded in the neck by paranoid schizophrenic Zephaniah McLeod on 6 September 2020.
McLeod, who was 27 at the time of the attacks, was sentenced to life with a minimum term of 21 years in 2021, after admitting the manslaughter of Mr Billington, four counts of attempted murder and three charges of wounding, in relation to seven other people he attacked that night.
Following a two-week inquest, senior coroner Louise Hunt said agencies had failed to communicate effectively and had not managed the release of McLeod from HMP Parc in South Wales well enough.
He had only been released five months before he launched the string of attacks in Birmingham city centre.
McLeod had been known to mental health services since he was diagnosed with paranoid schizophrenia in 2012, but did not regularly engage with them or take his prescribed medication.
Concluding the inquest on Friday, senior coroner Louise Hunt said that by the time Birmingham and Solihull community mental health teams had identified an address where McLeod had been released to in June 2020, he had already moved somewhere else and no further attempts to find him were made until he attended a new GP surgery on August 10 2020 asking to be prescribed anti-psychotic medication.
Mrs Hunt said: "(McLeod) had a long history of violent offending and was known to be a high risk of harm to the public and to have sporadic compliance with anti-psychotic medication, but there was no lawfully available control that might have been placed upon him at the end of his sentence to protect the public from the recognised high risk he presented."
Mrs Hunt also said the mental health in-reach team at HMP Parc failed to conduct a risk assessment or put any care plan or risk management plan in place and there was an "absence of adequate co-ordination" between all the different agencies involved with his resettlement and release planning.
She added: "The failure to adequately manage his release to Birmingham and the failure to ensure the community mental health team were notified of his release resulted in a lost opportunity to assertively manage his serious mental health condition and this possibly contributed to his mental health state on September 6 2020.
"Whilst it cannot be said that he probably would have then complied with treatment offered for his significant mental health needs, there is a realistic possibility that he would have done so."
The coroner said she would be writing a report to prevent future deaths which would highlight her concerns with the management of McLeod's release and lack of inter-agency working, critical information not being shared and a difficulty in finding key information about prisoners due to a number of systems being used by different teams within prisons.
Mrs Hunt said she was also concerned that there was no guidance available for when a high-risk prisoner is released at the end of their sentence to ensure that there had been adequate planning for that release.