Christina Edkins: Key points and recommendations outlined by inquiry into tragedy
A damning report today highlighted failings across a number of key areas at the root of the care of Christina Edkins' killer Phillip Simelane.
It found the public is still being put at risk of harm by violent criminals with mental heath problems being released from prison.
Simelane had a history of violent outbursts, including making threats of murder.
It said prisoners were being released without adequate 'support and supervision' in a move described as an 'extreme concern' by report authors Niche.
The report has made 25 recommendations across the public sector but says 'many of the same' failings highlighted in a previous NHS investigation in 2014 are still ongoing.
On prisoners being released early
The report found a problem in mentally ill prisoners being released early without required aftercare. It also found just 20 per cent of prisoners had a registered GP.
NHS England regional medical director David Levy said: "There is one recommendation, this is it. To ensure that prisoners leaving prison care where there are mental health issues identified leave in a safe way and are identified to health and social services.
"I'm delighted to report that the Ministry of Justice, Department of Health and NHS are actively addressing that issue at the moment."
Director of report authors Niche Nick Moor said: "As an investigation panel we were concerned that prisoners with mental problems who were released early from prison where there was insufficient communication between prison healthcare and prison service to arrange aftercare for them. And that still happens. It remains a serious concern that there are prisoners with mental health problems who are released from prison that don't always get access to support services they need."
On holding individuals to account
The NHS refused to hold individuals account for the lack of treatment given to Simelane ahead of him killing Christina.
This was despite references in the report to failings by professionals in assessing the killer.
Clinical commissioning Groups, Birmingham South Central, Dr Andrew Coward, said: "The independent report and initial investigation absolutely know that this was system failure and not individual failure.
"We all want the same thing, whether we are citizens, patients or doctors or nurses.
"We want safer systems. In order to get safer systems, we need the system to improve. I emphasise this is not about the individual, it is about the system. If we go down the individual route, systems will not become systems."
"It was because those individuals were working in those systems that the failures happened, it was not because of the individual."
He added: "I'm not here today to scapegoat anyone. It was due to multi system failure."
On the response to concerns raised by Christina's family
The health bosses also responded to comments from Christina's family, criticising the overuse of the term 'lessons will be learned' and fearing no major changes have been made.
Clinical commissioning Groups, Birmingham South Central, Dr Andrew Coward, said: "I can fully understand. I suppose we all have different roles, but to have been a family members and to have experienced the tragic homicide of your daughter, I completely accept and understand the statement they have issued, I can understand why they have a different view of predictably.
"If I had been in their issues, I would have issued a very similar statement, but as a doctor, I can understand why the independent report has said what it has said about predictability.
"The truth is when people are severely mentally ill, it is very rare and unusual for violence to be perpetrated on a stranger.
"For me as a father, as a doctor, as a commissioners in the local health service there is a balance between understanding where Christina's family are coming from, but also understanding the thrust of the report."
On changes needed to the law
The report authors said part of the problem over assessing prisoners' mental health was a conflict between the individual's right to privacy and public safety.
Director of report authors Niche Nick Moor said: "It is not about changing the law, it is about changing the understanding and application of the law.
"You couldn't make a general principal that all information from the criminal justice services could be shared with all the GPs.
"Because that's an invasion of privacy. But where there is an understanding of risk, then what I would expect is that the services then work together to improve communications."
On fears of a similar tragedy happening in the future
Health bosses could not rule out the incident happening again, but said improvements had been made.
Clinical commissioning Groups, Birmingham South Central, Dr Andrew Coward, said: I suppose some of the issues that we are discussed are some of the most difficult and complex facing modern society.
"How do we balance the freedom and the rights of mentally ill and vulnerable people with the safety of society. I am confident our city is after than it was, but there is still much work to be done, both locally and nationally. And we're committed to get this piece of work done."
An outline of the 25 recommendations made to organisations to focus on improvements
HMP Hewell & HMP Birmingham - Staff must liaise with all agencies to build up accurate profile of prisoner's needs and risk to others.
Department of Health, NHS England, CCGs, Police and Crime Commissioners - To work in partnership to roll out and develop street triage service to reduce impact of mental health on local police and emergency services.
NHS England health and justice commissioners, prison health care service, Ministry of Justice - Work together to improve discharging plan for vulnerable prisoners with mental health problems released earlier than planned and produce clear guidelines
NHS England & Ministry of Justice - Look into how law can be changed to make it easier to share health records of prisoners at risk of mental health problems who refuse their GP from disclosing their record.
Prisons, NHS, councils, ambulance service, Crown Prosecution Service - Agree more information sharing protocols.
NHS England, prisons - Ensure prisoners with mental health problems released from jail have appropriate care after release.
Forward Thinking Birmingham, & prisons - Review new services that ensure young offenders are supported when released.
Forward Thinking Birmingham and NHS Birmingham CrossCity CCG - Ensure development of services for vulnerable young people who use mental health and criminal justice services.
All local and national organisation involved in the case - Hold a 'lessons learned' day as soon as practical.
NHS England - Give guidance and who is responsible for serious incident investigations when they cross borders and organisations.
Black Country Partnership NHS Foundation Trust - Give clear guidance on how clinicians can work with other agencies and young person's family in the assessment and support planning processes.
Black Country Partnership NHS Foundation Trust - Records must include details of other agencies involved in cases.
Black Country Partnership NHS Foundation Trust - Ensure services are culturally sensitive and understand potential impact of immigration on the the family
Sandwell and West Birmingham CCG, Birmingham CrossCity CCG, and GP practices - Share learning from the investigation and roll out better safeguarding practices
Sandwell and West Birmingham CCG and GP practices - Review systems in place to identify and support parents of children who have mental health problems and ensure they are providing appropriate levels of support.
West Midlands Police - All agencies should assess if police should remove safety and alert equipment from a victim of domestic violence.
Prisons - Staff to familiarise themselves with new Home Office guidance.
Black Country NHS Foundation Trust - Must record other agencies involvement and contact details.
Black Country NHS Foundation Trust - Trust to make sure new DNA/No Access Visit policies are complied with.
HMP Hewell, NHS England health and justice team - Discuss findings of original report with new provider of healthcare at HMP Hewell to ensure lessons are learnt.
Birmingham and Solihull Mental Health NHS Foundation Trust - Discuss guidance with all prison health care services.
HMP Birmingham & Birmingham and Solihull Mental Health NHS Foundation Trust - HMP Birmingham to provide assurances that issues with obtaining prisoner medial notes have been resolved.
West Midlands Police - Involve family and carers about information sharing.
HMP Hewell & HMP Birmingham - Staff to record any contact with prisoners' families.
NHS England health and justice service, prison health providers, G4S, and Ministry of Justice - Consider what action can be taken to allow prison health teams access to prison records.
