Christina Edkins report 'reveals failures to stop her killer'

Christina Edkins, aged 16, was attacked while on the top deck of a number 9 bus to Leasowes High School by paranoid schizophrenic Phillip Simelane.

Simelane had a history of mental illness, but had been released from prison unsupervised prior the attack in March last year.

He was sentenced to an indeterminate hospital order after pleading guilty to manslaughter on the grounds of diminished responsibility.

Today, the Birmingham Cross City Clinical Commissioning Group published a review into her death.

Its key points include:

• The Black Country Partnership NHS Foundation Trust's Child and Adolescent Mental Health Services team should have been more engaged with Simelane's GP after he failed to attend appointments with the team in 2005. This was a 'missed opportunity to bring him back into contact with mental health services.

• After imprisonment at HMP Hewell for three months in October 2012 for threatening mother with knife, Simelane's GP was not notified of his prison term or concerns over his mental health or his release from prison. Simelane was released with three days' supply of medication - and no booked appointment for further supply.

• Seven days before his release from HMP Hewell, the forensic specialist registrar at the prison asked for a re-assessment for admission for Simelane and requested a referral to a home treatment team if he did not meet criteria for psychiatric hospital detention. This was not followed up.

• After reoffending, Simelane was admitted to HMP Birmingham in October 2012, before release two months later. The report found his release 'was said to be unexpected and at short notice'. He was seen by the prison consultant psychiatrist on day of release, but a 'comprehensive understanding of his previous assessments and treatment was not achieved by the time of his release', according to the report.

• Simelane was released with no communication made with Birmingham and Solihull Mental Health Foundation Trust's homeless team, despite this being intended. The national healthcare record system also failed to show he had a GP. Simelane's GP was not notified of release.

• Simelane gave an address on release - but this was a bail address, and the report said because it was 'a normal sounding address, it was not questioned'. He was regarded by the prison system as having an address to go to - but this was not sent to nurse assessing him at prison reception, who noted he had no fixed abode.

• Simelane had 17 mental health reviews undertaken by four different organisations between 2009 and 2012. At HMP Birmingham he was only seen by a psychiatrist on the day of his release from, despite a recommendation for an appointment made earlier during his imprisonment.

• Following Simelane's attack on Christina, he was assessed by two consultant forensic psychiatrists from the Birmingham and Solihull Mental Health Foundation Trust, they found he was mentally ill and should be detained under Mental Health Act.

In a statement, Christina's family said: "The report clearly shows that long-term failings by members of the police, prison-service and medical staff effectively to deal with and treat Philip Simelane during eleven years of a developing mental illness, culminated in a series of mis-managed opportunities throughout the fourteen months leading up to Christina's death on a bus in Birmingham.

"The facts detailed in the investigation into Simelane's behaviour during this time record his escalating acute paranoid psychotic disorder and show clearly that he was becoming increasingly dangerous to the public at large.

"We agree with the investigation panel findings that the fatal attack on Christina could have been prevented had he received appropriate treatment and that there were many missed opportunities for the provision of mental health treatment and follow-up."

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They say his illness and events such as attacking a police officer, family members and concerns raised by medical experts mean he should have received treatment in a secure hospital.

Halesowen & Rowley Regis MP James Morris was among the first to react to the findings:

The statement continues: "That this was not carried out was due to continued failings by many individuals, and systems which perpetuated those failings, in the Birmingham and Solihull Mental Health Foundation Trust, HMP Hewell and latterly HMP Birmingham.

"As a result, a paranoid psychotic was left to his own devices, without continued medication, a vagrant living on buses without help or supervision from our public services - this is the person who killed Christina on one of those buses."

The family said they hoped recommendations in the report would be carried out and called on the Birmingham Safeguarding Children Board and NHS England monitor the situation.

In October, Christina's great-uncle Chris Melia spoke to the Express & Star about Christina's death:

Murders taught me value of life says top West Midlands Police officer

More to follow....