NHS Trust Could Have Prevented Teenagers Death
15 June 2017, 09:06 | Updated: 15 June 2017, 10:30
Health services in Birmingham and the Black Country could have prevented the death of teenager Christina Edkins.
The 16 year old was stabbed to death on a bus on Hagley Road in the city by mental health sufferer Phillip Simelane.
A second investigation by health workers has found support should have been given to him earlier and that could have stopped him stabbing her.
Publication of the report by NHS England comes three years after a separate homicide review said Christina's death followed a series of "mismanaged opportunities''' to identify Similane's acute psychotic disorder.
The previous inquiry also found the death of Christina, from Birmingham, could have been prevented if her killer had received appropriate treatment.
Simelane, from Walsall, pleaded guilty to manslaughter following the random stabbing on a bus in Birmingham in March 2013, and was detained indefinitely under the Mental Health Act.
The largest concern is that despite these efforts the challenges to ensure appropriate after care on the release for prisoners with mental health problems remains.
"If we were able to make one recommendation to improve services and reduce the likelihood of such a tragic event happening again, it would be that the national services – Dept of Health, NHS England and MoJ strenuously work together to improve the after care of prisoners with mental health problems."
‘P’ was released from HMP Hewell (15 October 2012) with just three days’ supply of his medication and no follow up or after care. When he was arrested again five days later he went to HMP Birmingham – where he denied having any problems, missed appointments and his previous mental health records were not reviewed.
"We found it was predictable that P’s mental health would deteriorate. He had multiple risk factors, including a history of threats towards his mother. He was released into the community without access to mental health support or supervision. During the 3 months P was unsupported and unsupervised in the community.
No assessment of the increasing risk he presented could have been made, on this basis it was not predictable that P would kill a person completely unknown to him’ – Christina’s family say this ‘simplistic test of predictability is ‘misleading’
‘We agree with the initial investigation findings that it is likely that the homicide might have been prevented, if his mental health needs had been better identified and met. If P’s care had been coordinated and he had received ongoing support in the community after his release from prison.
Christina’s family say in a statement that they ‘continue to believe that failings within the NHS and Prison Service led directly to her death.’
They also say ‘Reading this report has been extremely hard for us as it has reopened the wounds we have tried to cover up every second of every day as we go about our lives putting on an act as if everything is normal’
Statement from Phillip’s Family: "The second investigation has been good – it got to the depth of the ‘how’s' and what next but it left the essential ‘whys’. Our son was discriminated against by the system that was put in place to protect him.’ His mother says her concerns were not heard by services.
Many of the initial recommendations on information sharing are not completed. In the summary of the report it says that they ‘still need to be addressed by changes in the law and through the joint efforts of NHS England and the MoJ’; for example a new national system for prisons – which will facilitate improved clinical information sharing on reception and on discharge, which is due to be completed in Autumn 2018.
There’s also still a problem that 20% of prisoners release aren’t registered with their GP.
Black Country Partnership NHS Foundation Trust Response:
"Much has changed over the last few years within Black Country Partnership NHS Foundation Trust. There are several new services, which if available for P when he was younger could have made a difference."
"14 of the 25 recommendations have been completed, the rest are still in progress."
Published in September 2014, the 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: "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.
"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.''
The report's authors made 51 recommendations to seven agencies involved in the case for changes to processes, practices and partnership-working.
The NHS announced a second inquiry into the care given to Simelane in November 2014 after the initial report was reviewed by an independent committee.