Four opportunities were missed by the authorities to better understand the risk posed by a violent and mentally ill man before he was released from prison and went on to carry out a fatal knife attack, a report has found.

Zephaniah McLeod stabbed Jacob Billington, 23, to death in September 2020 during a series of attacks on victims he chose at random in the early hours of the morning in Birmingham City Centre.

He stabbed seven other people causing serious and life-changing injuries.

Mr Billington’s mother has blamed “astonishing failings and incompetence”, saying prison, probation and mental health services “completely failed the public in their duty to keep us safe”.

Jo Billington 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. I will never see what Jacob would have become. He died due to a catalogue of errors and poor practice, and this I simply can’t forgive.”

McLeod ‘not subject to any form of supervision’ after prison release

An independent investigation commissioned by the NHS has found that five months before carrying out the attacks McLeod, who has paranoid schizophrenia and a long history of violent offences, was released from HMP Parc in South Wales “on his sentence end date and was not subject to any form of supervision, nor was he obliged to engage with agencies such as the police if they were to offer him any support”.

It details how prior to that McLeod had told a number of professionals over several years that he could hear voices.

It was also known that he had a history of refusing to take his medication.

In 2018, he told a psychiatrist that he was “hearing voices, both male and female telling him to “kill ’em… stab ’em… they are talking about you”.

Following his release from prison in April 2020, there was no record of where he had gone and by July he was deemed to be “lost to services”.

He contacted a GP in August 2020 and a non-urgent referral was made to the Birmingham and Solihull Mental Health NHS Trust and he was offered an appointment on 3 September.

After McLeod refused to attend, a new date was set for 24 September. By then he had carried out the attack.

McLeod sentenced to life

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

The report outlines contact McLeod had with the authorities – from the time he was first known to the police and criminal justice system in 2007, when he received a caution at the age of 14.

Between 2011 and 2020, he spent most of his time in prison for a string of violent offences. During that time he “was not appropriately treated and medicated”.

Five recommendations have been made to 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.

It also recommended that the West Midlands MAPPA (Multi-agency public protection arrangements) 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.

Anne Callaghan, whose son Michael suffered life-changing injuries in the attack, said: “Surely it is the government’s job to protect the public.

“I believe this incident was clearly predictable and preventable. It has devastated the lives of eight people and all those who care for them; Jacob and Michael are seemingly tolerable statistics to those who resource the system.”

‘These are not missed opportunities’

Mrs Billington said: “We are told about ‘missed opportunities’.

“These are not missed opportunities, these are people not doing their job, these are procedures not being followed and a catastrophic lack of professional standards, leading to a young man losing his life.

“This report, in my opinion, has some very weak recommendations that fail to get to the heart of what went wrong here – different organisations not seeking or sharing information as they are required to do, and procedures and working practices not being followed.

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“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.

“It is hard to feel reassured that anything will change at all. The situation in Birmingham is not safer than on the night Jacob died.”

NHS England Midlands medical director, Jess Sokolov, said: “I think the first response has to be once again to extend sympathies to the victims and the families, all those who were affected. There was a horrific sequence of events that took place in September 2020.

“What the report is seeking to do is understand where there are missed opportunities, where things could have been done differently and where perhaps next time that would result in a different outcome.”

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A spokesperson for Birmingham and Solihull Mental Health Foundation Trust said: ”We would like to publicly express our sincere sympathies to the families and friends of Jacob and Michael.

“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.”

Sky News has contacted the Ministry of Justice and is waiting for their response.

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