Zephaniah McLeod: Report into Birmingham stabbings slams 'missed opportunities' to stop knifeman

Zephaniah McLeod
Zephaniah McLeod Credit: West Midlands Police

An inquiry report into a knifeman's stabbing spree in which one man died and seven others were injured, has found a string of "missed opportunities" to recognise the risk around the man responsible.

An independent investigation into the supervision of paranoid schizophrenic Zephaniah McLeod, which was commissioned by the NHS, said he was released from HMP Parc in South Wales "with no planned contact with statutory services" five months before he carried out a series of early-morning knife attacks in Birmingham on 6 September 2020.

The report found there were four missed opportunities to better understand McLeod's mental health and "allow for a planned release" from prison.

McLeod carried out three stabbings in the city centre before taking a taxi home, re-arming himself, and then going back to continue his rampage.

McLeod on his rampage in Birmingham Credit: West Midlands Police

The attacker, who was 27 at the time of the attacks, was sentenced to life with a minimum term of 21 years at Birmingham Crown Court in 2021, after admitting the manslaughter of Jacob Billington who was 23, four counts of attempted murder and three charges of wounding.

"Astonishing failings and incompetence"

The families of Mr Billington, who worked at Sheffield Hallam University, and his life-long friend, Michael Callaghan, who received life-changing injuries, both provided impact statements to the review into how the multiple government agencies acted.

Mr Billington's mother, Jo Billington, said in her statement that she had been "left utterly heartbroken" by his killing, and "the subsequent discoveries about how much the different agencies knew about this man".

Jacob Billington (l) and his friend Michael Callaghan (r) who was badly injured

Claiming the report had made "very weak" recommendations that failed to get to the heart of what went wrong, she said: "The (crown court) judge was very critical in his sentencing report about the level of care and monitoring of this individual."

The court heard McLeod, from Nately Grove in Selly Oak, suffered from paranoid schizophrenia, and a Section 45A Mental Health Act order was made which sent McLeod to a secure hospital.

McLeod had a string of previous convictions, including for robbery and possession of a firearm and knives.

He was arrested at least 21 times between 2007 and 2017, and was well known to mental health services.

  • The moment Mcleod was arrested by armed police

The NHS England report published today criticised the Mental Health In Reach teams, which failed to properly understand and treat his known mental health conditions while in prison. 

What did the report find?

  • McLeod moved between prisons and there was no continuity in the treatment of his mental health conditions (namely paranoid schizophrenia)

  • No evidence that any of the prison Mental Health In Reach Teams (MHITs) reviewed the historical assessment information available to them, with each team in each prison instead doing a new assessment

  • MHITs didn't follow up with cell visits when McLeod didn't attend appointments

  • MHITs 'lacked professional curiosity' and understanding of his mental health needs, and didn't consider certain behaviours (like hiding in cell with head under blanket) in the context of his known conditions

  • McLeod's release from prison in 2020 meant that because of Covid restrictions, no proper planning or co-ordination of local services was put in place for his release and the MHITs weren't allowed into prison

  • Missed opportunities while in prison to refer him to secure mental health units

  • McLeod's risk to the public was not considered in the context of his mental health, only his criminality

McLeod is referred to throughout the report by the initial H. In its conclusions, the report's authors noted:

"This review has concluded that H was not appropriately treated and medicated from 2011 to 2020.

"H consistently did not engage with any of the statutory services he came into contact with, from the police, prison, and probation service to local community mental health services.

"This pattern of non-engagement with services resulted in him being discharged from MAPPA in October 2019, because the panel could not see a role for itself.

"It also resulted in H remaining in prison until his sentence ended.

"The consequence was that he was released from HMP Parc in April 2020, subject to no statutory supervision from any of the criminal justice services - police or probation."

The report also noted that McLeod was released from jail to no fixed abode, so services had no idea where he had gone. The report said:

"He had told services he was going to North Wales but, in reality, he returned to the Birmingham area on the day of his release".

Zephaniah McLeod Credit: West Midlands Police

What are the report's recommendations?

  • Improve services, including a call for the Birmingham and Solihull Mental Health Foundation Trust to develop an up-to-date operational policy covering prison discharge services

  • The West Midlands MAPPA Strategic Management Board reconsider its decision not to complete a serious case review, which the report's authors said would be an opportunity to look in more detail at the issues it had raised

  • A call to ensure the mental health in-reach team at HMP Parc has sufficient resources to meet demand

Julian Hendy, the director of the Hundred Families charity, which has been supporting relatives of Jacob Billington and his injured friend Michael Callaghan said the report is "truly shocking".

"It demonstrates in very clear detail that agencies which are supposed to protect the public failed to effectively monitor a highly dangerous, violent, and seriously unwell man," he said.

"Unfortunately, this is not the first time this has happened in Birmingham.

"In 2013 16-year-old Christina Edkins was fatally stabbed by a recently released prisoner with serious mental health problems.

"After similar investigations then we were promised that 'lessons will be learned' so that no other family would have to endure a similar loss in future. But that clearly hasn't happened."

A spokesperson for Birmingham and Solihull Mental Health Foundation Trust said the organisation "fully accepts" the recommendation for them to review the service description of its discharge service.

"We would like to publicly express our sincere sympathies to the families and friends of Jacob and Michael," the trust said in a statement.

"Our chief executive and interim chief nurse met with Jo Billington and Anne Callaghan and were deeply saddened to see the terrible impact that this tragedy has had on them and their families' lives.

"As an organisation, we fully accept the recommendation in the report for us to review the service description of our discharge service.

"We have commissioned a comprehensive review and will update the service description accordingly, to help ensure a similar incident does not occur."

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