THE report into the mistakes of various agencies across Birmingham, Worcestershire and the Black Country which failed to prevent paranoid schizophrenic killing Christina Edkins has made 51 recommendations.

There were 17 mental health reviews or formal assessments undertaken by four different organisations, involving a number of healthcare professionals, between April 2009 and December 2012, but none of which resulted in Simelane being sectioned under the Mental Health Act.

Responding to the report, Halesowen and Rowley Regis MP James Morris and chairman of the All-Party Parliamentary Group on Mental Health, said: “This is an extremely thorough report that uncovers a string of mistakes and failures by mental health services, the police and the prison service, going back 12 years and culminating in Christina’s brutal murder last year.

“Tragically, nothing can ever bring back Christina but it is vital that the lessons in this report are learned so that other families do not have to suffer the pain and loss caused by the murder of a loved one.”

Birmingham and Solihull Mental Health NHS Foundation Trust, Black Country Partnership NHS Foundation Trust, HMP Hewell, HMP Birmingham, Simelane’s GP, West Midlands Police, the Crown Prosecution Service and social services all were criticised in the report.

John Short, chief executive of BSMHFT, said: “This is an extremely distressing case and our thoughts are very much with the families involved. We fully accept the review’s findings and acknowledge that we must learn from what happened.

“The review panel has confirmed that Christina's death could not have been predicted, but it was preventable because had there been intervention to address Phillip Simelane's mental health needs, there may have been a different outcome.

“The report also highlights the complexity of the case, which involved a significant number of different organisations and care professionals over a number of years.

"This Trust’s involvement was through mental health assessments during two prison terms in 2012 for unrelated offences."

He added: “BSMHFT has led this comprehensive review on behalf of all the parties involved.

"We agree with the recommendations relating to our Trust.

"We are already addressing these through a robust action plan, in particular: new guidelines and protocols for assessments undertaken in prisons - covering issues of training, supervision, clinical audit, information-sharing and record-keeping.”

The report states: "There were 17 mental health reviews or formal assessments undertaken by four different organisations, involving a number of healthcare professionals, between April 2009 and December 2012. None of these assessments resulted in P being detained under the Mental Health Act 1983 (Amended 2007).

A number of assessments were undertaken as stand alone assessments, but a longitudinal assessment was undertaken over a period of three months, during his stay in HMP Hewell healthcare, between July and October 2012.

There was an opportunity for a further longitudinal assessment of his mental health during his time in HMP Birmingham, but he was not seen by a psychiatrist until the day before his release, despite this having been recommended early in his detention.

Three mental health assessments were undertaken by the Black Country Partnership NHS Foundation Trust. All three risk assessments, undertaken in May and July 2012, were undertaken in Sandwell Magistrates Court. There were six assessments undertaken by a Forensic Physician whilst Simelane was in police custody.

Police records indicate that he was regularly uncooperative whilst in police custody and also on a number of occasions during medical and mental health assessments.

The BSMHFT Psychiatric Intensive Care Units team undertook a prison assessment in September 2012 which did not result in admission.

He was also assessed by a Consultant Psychiatrist in HMP Birmingham on December 12, 2012, the day before he was released from prison."

The recommendations include better sharing of information within organisations and between other agencies to identify prisoners and mental health patients in danger of committing violent crime.

The report and full list of recommendations can be found at www.bhamcrosscityccg.nhs.uk.