'Missed chances' to stop killer
The fatal stabbing of a 16-year-old girl could have been prevented if her killer had received appropriate treatment for mental health problems, an official report has found.
A homicide investigation review team said Christina Edkins' death at the hands of Phillip Simelane followed a series of "mismanaged opportunities" to identify an acute psychotic disorder.
Simelane, from Walsall, pleaded guilty to manslaughter following the random stabbing on a bus in Birmingham in March last year, and was detained indefinitely under the Mental Health Act.
A multi-agency investigation into the killing, co-ordinated by NHS Birmingham CrossCity Clinical Commissioning Group, highlighted long-term failings by members of the police, prison service and medical staff.
Commenting on the report's findings, its chair Dr Alison Reed said: "Throughout this review, the families involved have been uppermost in our thoughts.
"We have been determined to address their concerns and there has been a commitment from the outset to publish our report, which we have already shared with the families.
"It is clear that there were missed opportunities, particularly for organisations and professionals to work together more closely in heeding the repeated attempts by (Simelane's) mother to secure help for her son.
"The attack on Christina was random and unprovoked and therefore it could not have been predicted.
"However, it is the conclusion of the panel that as Christina's death was directly related to (Simelane's) mental illness, it could have been prevented if his mental health needs had been identified and met.
"While it is impossible to remove risk entirely, we sincerely hope that our recommendations will help to reduce such risk in future."
Simelane, then aged 23, was released from prison three months before the killing but did not receive treatment despite concerns for his mental state.
The report's authors made 51 recommendations to seven agencies involved in the case for changes to processes, practices and partnership-working.
In a statement, Christina's family said the report showed that failings over 11 years of Simelane's developing mental illness had "culminated in a series of mis-managed opportunities" during the 14 months prior to the killing on March 7.
The family statement added: "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.
"We believe that it was predictable that, without treatment, Phillip Simelane would eventually resort to a knife attack on another person and it was only a matter of time before he carried out his threats to kill.
"We are hopeful that the many recommendations contained in Dr Reed's report are implemented and the learnings are 'embedded' in the organisations so that no other family has to experience the heartache of such a meaningless and avoidable death of a loved one."
Simelane, who was arrested near the scene of the stabbing, is known to have previously been involved in attacks on family members, including an incident in which he held a knife to his mother's stomach.
The report also disclosed that Simelane had threatened to stab and kill his mother whilst on oath in a magistrates' court.
The report concluded that organisations failed to listen and respond to carers and significant others consistently and adequately.
Simelane's family also issued a statement in response to the report, saying their hearts went out to Christina's relatives.
The Simelane family said: "An incident that could have been avoided has changed our lives.
"We make a heartfelt plea to the Government to take measures to ensure corrective systems and procedures are put in place immediately to prevent the continued re-occurrence of these tragic incidents."
Dr Gavin Ralston, the chair of Birmingham CrossCity CCG, said: "My heart goes out to the families, friends and relatives whose lives will have been devastated by this terrible event.
"I thank the investigation panel for its work and I strongly urge all the organisations involved to complete their implementation of the recommendations as soon as possible."