Prisoner released ‘without support for mental illness’ before deadly knife rampage

A university worker was unlawfully killed on a night out by a paranoid schizophrenic who was released from prison months earlier “without any support in place for his serious mental illness”, a coroner has ruled, as she highlighted “lost opportunities” to effectively manage his condition.

Sheffield Hallam University graduate worker Jacob Billington, 23, was killed and his lifelong friend Michael Callaghan was seriously injured when mentally ill knifeman Zephaniah McLeod went on a 90-minute rampage through Birmingham city centre in the early hours of September 6 2020, in which he also wounded six other people.

McLeod, who was 27 at the time of the attacks and lived in Nately Grove in Selly Oak, was sentenced to life with a minimum term of 21 years at Birmingham Crown Court in 2021, after admitting the manslaughter of Mr Billington, from Crosby, Merseyside, and four counts of attempted murder along with three charges of wounding.

A two-week inquest into the death of Mr Billington heard that McLeod, who had a long history of offending, 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 inside or outside of prison.

The court heard McLeod had long reported hearing voices telling him to kill or stab people and saw shadows, but did not regularly take the anti-psychotic drugs he was prescribed, believing his medication to be homing devices used by the government to monitor him, and refused to speak to psychiatrists in prison or engage with mental health services.

Despite being deemed a high risk of serious harm to other people, McLeod was released from HMP Parc in South Wales on April 22 2020 after a three-year prison sentence for drug and firearm offences five months before he killed Mr Billington without any support in place for his mental health and was released back to Birmingham with no fixed address.

Concluding the inquest on Friday, senior coroner for Birmingham and Solihull 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.”

The inquest heard a meeting to discuss multi-agency public protection arrangements (Mappa), which are put in place to ensure the successful management of violent and sexual offenders, was held a month after McLeod arrived at HMP Parc in 2019 – but the prison was not invited to take part and did not know about it.

At that meeting, McLeod was dropped from a level two risk, for cases where active interagency management is required to manage the risk of serious harm posed, to level one, effectively discharging him from Mappa management – not because he was no longer a risk, but because he would not engage and he was reaching the end of his sentence.

Mrs Hunt said Mappa’s involvement was “prematurely ended without any plan in place aimed at ensuring a co-ordinated release from prison” and that some of the actions prescribed by Mappa relating to liaison with McLeod’s local community mental health team were not completed.

She said: “The Mappa process did not effectively promote risk reduction as it discharged him without plans in place for a co-ordinated approach to the care of the perpetrator in prison or to ensure interagency planning for his release.”

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.

Addressing Mr Billington’s family who were in court for the inquest alongside Mr Callaghan’s mother Anne, Mrs Hunt paid tribute to the “much-loved son, brother and friend” with a “fantastic personality”, and said: “My thoughts are with all of you at this difficult time as I know this inquest has brought back awful memories.

“I do hope lessons can be learned from Jacob’s tragic death.”