Birmingham stabbings: Killer Zephaniah McLeod was released from prison unsupervised

Jacob Billington, pictured with sister Abbie, was fatally stabbed by Zephaniah McLeod

A mentally-ill man who went on a fatal stabbing spree had been released from prison unsupervised, a review found.

Zephaniah McLeod, who has paranoid schizophrenia, killed Jacob Billington and hurt seven others in Birmingham.

Mr Billington's mother said a multi-agency review into McLeod's treatment showed a catalogue of "astonishing failings and incompetence".

Agencies knew McLeod had made threats to hurt people and in the end he had carried out those threats, she said.

Jo Billington said the report into what led up to the stabbings on 6 September 2020 made "very weak" recommendations that failed to get to the heart of what went wrong.

"There appear to be no consequences at all for the agencies involved, and I am not satisfied in any way the failings identified in this report will not continue to happen," she said.

"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."

Jo Billington told the BBC she believed son Jacob would still be alive if agencies had worked together and adequate risk assessments were done

Her son, a 23-year-old Sheffield Hallam university librarian, from Crosby, Merseyside, had been enjoying a night out with friends when he was attacked.

His lifelong friend Michael Callaghan who was gravely injured would suffer "the horrendous consequences of his injuries for the rest of his life", she added.

McLeod, 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.

The then 27-year-old had carried out a number of attacks, moving across Birmingham city centre until he came across a group of friends which included Jacob Billington and Michael Callaghan.

He stabbed them both in the neck, Jacob fatally and he died at the scene. Michael went on to have a "catastrophic" stroke and was left completely paralysed down his left-hand side.

His mother Anne Callaghan, thanked NHS staff for their wonderful care of her son.

Michael Callaghan (right) was seriously hurt in the attacks and spent two months in a coma

But she stated: "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.

He had not been "appropriately treated and medicated" for nine years prior to the attacks, the review found.

Five months before the attacks, he was released from HMP Parc in Bridgend, Wales, after serving three years for drug and firearms offences.

He was released unsupervised and to no fixed abode and services "did not know where he had gone", the report said.

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", said the NHS-commissioned review.

He did not 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 himself.

Zephaniah McLeod carried out a series of stabbings across Birmingham over 90 minutes

Mental Health Inreach Teams (MHITs) in prisons were not assertive in monitoring and supporting his compliance with taking medication for his mental health problems, said the report.

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, the report said.

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 in the end did not as they said he was compliant wit his medication. But he was only compliant for five days, the report said.

He was removed from multi-agency public protection arrangements (MAPPA) in October 2019, due to not-engaging with any of the services.

This resulted in him remaining in prison until his sentence ended and not being supervised by police or probation services afterwards.

"Furthermore, his observed mental health symptoms were not considered to be of a degree or nature to reach the threshold for assessment or detention under the Mental Health Act," the report added.

Covid-19 restrictions also meant some services, such as a resettlement team, were not allowed into HMP Parc.

After being referred by his GP to a community mental health team he was visited at home on 3 September.

He 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 separate attacks across Birmingham.

Nick Moor, the report's co-author, said prisons were "not the right place" to treat serious mental illness

Nick Moor, Niche's associate lead for mental health investigations who co-authored the report, said the case was "particularly complex" as it involved 14 different agencies organisations and crossed the NHS in both England and Wales, he said.

"Prisons are not the right place to treat people with serious mental illness, that's the hardest part of this case really," Mr Moor said.

The report's recommendations include:

• Reviewing the description of Birmingham & Solihull Mental Health Foundation Trust's prison discharge service to clearly define its work and remit

• The National Probation Service and West Midlands MAPPA strategic management board must reconsider the decision not to complete a serious case review as one would allow issues raised to be looked at in more detail

• There should be guidance for MAPPA chairs to ensure discharge from multi-agency public protection arrangements should only happen when it involved full information from all services