This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.
On 9 September 2020 I commenced an investigation into the death of Jacob Michael Nicholas BILLINGTON. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Unlawfully killed
Circumstances of the death
Jacob was unlawfully killed when he was stabbed in the neck on 06/09/20 whilst on a night out in Birmingham with friends. A number of other people were also seriously injured that night by the same perpetrator over a 90 minute period. At the time of the attack the perpetrator was suffering from paranoid schizophrenia a severe and enduring mental illness which was characterised by him constantly hearing voices which at times told him to harm others including 'kill em'. The perpetrator had not been receiving regular prescribed anti-psychotic medication in the months leading up to attack and he also may have taken illicit drugs, both of which may have contributed to the deterioration his mental state.
On 22 April 2020 the perpetrator had been released from prison at the end of a three year sentence for drug and firearm offences. He 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 perpetrator had a long history of refusing to engage with agencies whilst in prison. Although he had been in the community on licence under MAPPA (Multi Agency Public Protection Arrangements) he was recalled to prison on 24/12/18. Shortly after his transfer to HMP Parc on 12/9/19 the MAPPA oversight was prematurely ended without any plan in place aimed at ensuring a co-ordinated release from prison and some of the actions that were prescribed by MAPPA relating to liaison with his local CMHT were not completed. The MAPPA process did not effectively promote risk reduction as it discharged him without plans being in place for a coordinated approach to the care of the perpetrator in prison or to ensure interagency planning for his release.
The secondary mental health services In Reach team at HMP Parc failed to conduct a risk assessment or devise any care plan or risk management plan, and there was an absence of adequate coordination between all the numerous agencies involved with him in respect of resettlement and release planning. It was known by 10 March 2020 that a requested resettlement in Wrexham was not going ahead and on 3 April 2020 that he was returning to Birmingham with no fixed address. This was not communicated to the relevant agencies including the Birmingham CMHT. On release on 22 April 2020 the perpetrator requested a travel warrant to Birmingham where he lived until the events of 06 September 2020 which was also not communicated. He was released without any support in place for his serious mental illness. By the time the Birmingham CMHT identified in June 2020 where he had moved to on leaving prison he had recently changed address and was also not being followed by the CMHT until after he had presented to a new GP on 10th August 2020 asking to be prescribed anti-psychotic medication and after a new care coordinator was in place. He was then seen, on the doorstep of his home on 03 September 2020 by a CPN when he declined to attend a pre-arranged appointment with the CMHT subsequent psychiatric who already knew him from an assessment undertaken in December 2018, but he did agree to have a short telephone conversation with that psychiatrist. A limited assessment was undertaken and it was reasonably planned to instruct the GP to restart him on medication and to review him in the clinic in several weeks' time. It is not known whether he received or took any medication. Three days later the perpetrator attacked seven wholly innocent members of the public in Birmingham City Centre and it was during these attacks that Jacob was killed.
The failure to adequately manage his release to Birmingham and the failure to ensure the CMHT 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 state on 06/09/20. 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.
Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:
1a SHARP FORCE NECK TRAUMA
1b
1c
II
Coroner’s concerns
1. Management of release and lack of interagency working. The management of the perpetrators release was not coordinated and there was inadequate communication between relevant agencies. In effect agencies worked in silos. Critical information is not being shared and agencies work in different IT systems meaning there is no one place where information is collated and hence a comprehensive account of matters known to each agency is not easily available to those professionals who may need to know a high risk prisoner’s whereabouts on release. This concern was reinforced by evidence heard during the inquest that changes made since Jacob's death did not include the resettlement information being given to Mental Health In reach teams in the prison. The failure to share information leads to a concern of future deaths as high risk seriously unwell prisoners may be released without key agencies knowing where they are meaning any are not traced and treated assertively in the community. 2. Sysmone Details of the perpetrators GP and local CMHT were not recorded in an easily accessible format. The format in which key information is recorded has now been amended at HMP Swansea to ensure the prisoner’s GP details and their CMHT’s details (if a person is an existing patient under a CMHT) are highlighted on a front screen/page. I was informed that this change in information management and presentation within Sysmone is unique to HMP Swansea and is not the practice in other prisons. I am concerned that there remains a risk that staff treating patients in prison may not have easy access to (and so overlook) this key information. 3. Cross agency guidance regarding release of high risk prisoners with mental health difficulties at their sentence end date. There are no provisions available nor any cross agency guidance in place for when a high-risk prisoner is released at sentence end date to ensure that there is adequate release planning and maximum support in the community. 4. West Midlands MAPPA has a prison discharge coordinator role. It was clear from the evidence at the inquest that this role was not fully understood by other agencies and what information needed to be shared was not clear. The new policy drafted by BSMHT remained confused as to which cases were to fall within the responsibility of the prison discharge coordinator role. There remains a risk of further deaths as the role is not properly understood and information sharing is not effective.
Concerns and recipient responses
Select any concern, action or position to view the source wording.
Report evidence summary
Concerns raised5
Failure to record prisoners’ GP and CMHT details in an easily accessible format
Failure to establish effective information sharing for prison discharge coordination
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.27
Action
Hold monthly strategy meetings monitoring first-night accommodation and whether released prisoners’ whereabouts are known to community services.
Stated byG4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Require offender managers to notify Community Offender Managers about sentence-end releases involving no fixed abode and provide release-destination information.
Stated byG4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Introduce resettlement-services drop-in sessions for prisoners approaching release.
Stated byG4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Roll out remote resettlement-services sessions using approved laptops.
Stated byG4SStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Continue streamlining internal data recording so information is shared through the national prisons IT system, DPS.
Stated byG4SStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Record travel-warrant destinations and email them to the OMU group for communication to relevant offender managers and agencies.
Stated byG4SStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Include the BSMHFT MAPPA Clinical Lead in developing a sustainable MAPPA engagement strategy and identifying alternative arrangements for gaps.
Use weekly discharge information, prison NOMIS access and a Governor Grade officer at Single Point of Access meetings to verify release dates.
Stated bySwansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Conduct multidisciplinary pre-discharge reviews and formal pre-release planning meetings four to six weeks before known release dates.
Provide documented discharge summaries and comprehensive handovers to primary care, general practitioners, patients and, with consent, probation officers.
Work with MAPPA partners to ensure the prison discharge coordinator role and policy are understood and cascaded to police MAPPA teams.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Visit managed offenders after prison release regardless of their MAPPA process status.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Work with agencies to clarify key roles and systems, improve information sharing and management, and protect the public.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Continue updating ViSOR records for each individual so information can be shared across agencies.
Stated byWest Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Provide policing support to partners concerning high-risk prisoners with mental health difficulties released at sentence end.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Promote the NHS Reconnect Service to probation practitioners to support referrals for through-the-gate transition support.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Revise and reissue the sentence-end-date release practice document, and embed its expectations in staff development sessions.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Action
Continue reviewing and refining MAPPA practices to improve interagency working and risk-information sharing.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
Action
Work with the Health Trust on guidance revisions for the prison discharge coordinator role to clarify responsibilities, information sharing and probation-service implementation.
Stated byHM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
Action
Reinforce the statutory information-sharing requirement for MAPPA duty-to-cooperate agencies.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.18
Position
Concerns about SystmOne, cross-agency release guidance and the MAPPA discharge coordinator fall outside G4S’s power to address.
Stated byG4SOutside remitThe respondent said that this matter was outside its role or authority.
Position
Other interested persons addressed by the report are better placed to consider concerns 2, 3 and 4 and determine any response.
Stated byG4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
G4S cannot implement changes to streamline IT systems used by HMPPS, the NHS and third-party providers.
Stated byG4SUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
G4S cannot influence release management or interagency working at private prisons operated by other providers or HMPPS.
Stated byG4SOutside remitThe respondent said that this matter was outside its role or authority.
Position
HMPPS is responsible for providing and operating resettlement services, which are delivered by HMPPS-commissioned external providers.
Stated byG4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Issues concerning information sharing on NDelius should be addressed to HMPPS.
Stated byG4SRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
National Systemone interface issues must be addressed by other Interested Parties, although the Trust is exploring a local amendment.
Liaison with MAPPA is the Offender Management Unit’s responsibility, while the Responsible Authority must notify Health and arrange relevant meetings.
Stated bySwansea Bay University Local Health BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The Health Board lacks jurisdiction or power over the cross-agency actions required for release planning at sentence end.
HMPPS will address cross-agency guidance for releasing high-risk prisoners with mental health difficulties at sentence end.
Stated byWest Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Access to and amendment of SystmOne are outside policing functions because it is used by healthcare professionals.
Stated byWest Midlands PoliceOutside remitThe respondent said that this matter was outside its role or authority.
Position
Partners managing the prison discharge coordinator role will address the role and amend the related policy.
Stated byWest Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
HMPPS cannot access, review or change SystmOne because it is an information system used by healthcare professionals.
Stated byHM Prison and Probation ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Health Trust is responsible for revising guidance for the prison discharge coordinator role; Probation will support that work.
Stated byHM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Probation has no statutory authority to supervise prisoners released into the community at sentence expiry.
Stated byHM Prison and Probation ServiceOutside remitThe respondent said that this matter was outside its role or authority.
Other statements in published responses
These actions and other statements could not be clearly connected to one concern in this report.
Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.20
1
Provide weekly supervision for Prison Discharge Coordinator practitioners, including opportunities to escalate cases of concern.
Participate in Strategic Management Board discussions on cross-agency release planning as a Duty to Cooperate agency.
Stated bySwansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
7
Generate, monitor and review Single Point of Access action plans at subsequent meetings.
Roll out team-wide training for access to the prison NOMIS system.
Stated bySwansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
12
Improve partnership working with pharmacy on medication pathways and escalation of non-compliance concerns.
Implement MHIR clinical standards covering referral, discharge, safety, training, workforce, medicines, governance, partnership working and the care environment.
Report audit findings through divisional, performance, partnership-board and clinical-audit governance forums, including monthly Care and Treatment Plan and risk-assessment audits.
Attend all Level 2 and Level 3 MAPPA meetings with authority to allocate appropriate police resources.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
17
Ensure offenders subject to notification requirements are registered, risk-assessed, visited, professionally managed and recorded on ViSOR.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
18
Ensure a senior leader, at least a Chief Superintendent, attends the MAPPA Strategic Management Board.
Stated byWest Midlands PoliceStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
19
Share learning from the death more widely with colleagues and continue using it to inform improvements across probation regions.
Stated byHM Prison and Probation ServiceStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
20
Present the case findings to the MAPPA Strategic Management Board.
Stated byHM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
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