A man who stabbed eight people in a series of unprovoked attacks was released from prison months earlier with no restrictions or supervision despite experiencing delusions, refusing to take medication and having made weapons in his cell, a report has found.
Zephaniah McLeod, who was diagnosed with schizophrenia, stabbed eight people during a late-night rampage in Birmingham city centre in September 2020, killing 23-year-old Jacob Billington who was walking back from a night out.
His best friend, Michael Callaghan, was stabbed in the neck and had a stroke that left him partially paralysed, and three others also received serious injuries.
An independent report published on Tuesdayon how mental health services, police, probation and prison services managed McLeod has concluded he “was not appropriately treated and medicated [for his mental illness] from 2011 to 2020”, during which time he was mainly in prison or released on licence.
“He did not engage with mental health services in prison or in the community” and would only take medication “for a matter of days”, the report says. “We observed more care plans relating to the management of [McLeod’s] asthma while in prison than his mental health problems.”
In the months leading up to his release, McLeod reported paranoia, frequently got into fights with inmates and prison staff, and was found to have a sharpened toilet brush in his cell, but he was seen by a psychiatrist only once in his final six months in prison.
When he was released in April 2020, during the height of the Covid pandemic, “services did not know where he had gone” until he sought help for his mental health in Birmingham months later. He had not seen a probation officer in person since 2018.
The report, commissioned by NHS England and compiled by a team of mental health and prison specialists, makes recommendations including a serious case review, better resourcing of the NHS-run mental health team at HMP Parc in south Wales, where McLeod was imprisoned in the months before his release, and a review of the prison release service at Birmingham and Solihull mental health foundation trust.
Billington’s mother, Jo, criticised the recommendations as “weak” and said they “fail to get to the heart of what went wrong here”.
She said: “The report catalogues a massive amount of astonishing failings and incompetence. It speaks to a terrifying lack of concern, or even interest in how dangerous this man was.
“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.”
A week before his release, McLeod refused to attend a psychiatric appointment, and staff reported he was “not taking his medication, not coming out of his cell, lying in bed with a blanket over his head”.
Probation services claimed they believed McLeod had moved to the Wrexham area on release as he said he wanted to escape the “gang culture” of Birmingham, although the prison had provided him with a travel ticket to Birmingham.
He was seen by the community mental health team at his home 48 hours before the stabbings and admitted to hearing voices, but refused to attend an appointment with a psychiatrist later that day, and one was rescheduled for later that month.
The report details McLeod’s long history of criminality, starting with arrests from the age of 14, and in 2011 he was sent to a young offender institution after a series of robberies in which he snatched gold chains from women’s necks in the street.
In April 2017 he was sentenced to 36 months in prison for drugs and firearms offences. He was released on licence to supported accommodation in November 2018 but was recalled to prison eight weeks later for breaching conditions.
The report concludes that McLeod’s “untreated schizophrenia contributed to his chaotic behaviour in the community” during this time, and there was a “lack of professional curiosity” from hostel staff over incidents such as his report of getting into a fight at a bus stop with a group of men he claimed were talking about him.
“This could have been an early warning sign of a deterioration in his mental health,” the report says. Weeks earlier, he had told prison mental health staff that he was “hearing voices, both male and female, telling him to ‘kill ‘em … stab ‘em … they are talking about you’.”
In October 2019, McLeod was deregistered from a multi-agency public protection arrangements (MAPPA) service, designed to manage violent and sexual offenders, due to his failure to engage with staff.
The report concludes there was “no evidence to indicate [McLeod’s] risk of harm had reduced sufficiently or that his case no longer required multi-agency involvement”.
