The mum of a Crosby man killed in the street at random by a knifeman slammed the "astonishing" failure of different agencies to realise the danger he posed.
Jacob Billington, 23, died after Zephaniah McLeod went on a stabbing spree in central Birmingham, attacking eight victims at random. University worker and musician Mr Billington was wounded in the neck and shoulder as he walked to a hotel following a night out to celebrate a friend's birthday.
McLeod also stabbed Mr Billington's close friend and bandmate, fellow Crosby native Michael Callaghan, in the neck, causing life-changing injuries. Mr Callaghan, then 24, was partially paralysed and suffered a stroke following the attack in the early hours of September 6, 2020.
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In 2021 McLeod, who has paranoid schizophrenia, admitted the manslaughter of Mr Billington on the grounds of diminished responsibility, four counts of attempted murder and three counts of wounding. He was jailed for life with a minimum term of 21 years in prison at Birmingham Crown Court.
Today an NHS commissioned independent investigation into how 27-year-old McLeod was monitored and supervised was published. The inquiry report found there were four missed opportunities to better understand McLeod's mental health and "allow for a planned release" from prison.
The families of both Mr Billington and Mr Callaghan were invited to submit statements to the review, which were scathing in their assessment of how McLeod was supervised. Mr Billington's mum, Jo Billington, said: "The (crown court) judge was very critical in his sentencing report about the level of care and monitoring of this individual.
"Finally, after a two-and-a-half year wait, we have this report. This is an unacceptably long time to wait for answers. Now we finally have it, it 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.
"Few people checked, few kept adequate records or assessed his risk effectively, or even at all. 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.
"There appear to be no consequences at all for the agencies involved, and I am not satisfied in any way the failings identified in this report will not continue to happen. All the agencies knew about the offender, they knew he was dangerous and violent, that he didn't comply with medication, and he had made multiple threats to hurt people.
"In the end, he carried out those threats. Eight innocent people have had their lives changed forever. I will never see what Jacob would have become. He died due to a catalogue of errors and poor practice, and this I simply can't forgive."
In his statement to the review, Keith Billington, Jacob's father, added that his son "was much loved, much wanted, and now - much missed" but had come "face to face with evil" on the night he was killed.
He worked hard and he played hard," Mr Billington said. "He was on the cusp of the next phase of his life when he would take everything he had learnt; the skills, the experience, the friendships and networks to build a great life for himself and his future family.
"But he had the misfortune to meet someone without any responsibility; who took him away from us."
In another statement to the inquiry team, Mr Callaghan's mother, Anne Callaghan, thanked NHS staff for their wonderful care of her son, whose capacity to work had been "catastrophically hit by his injuries."
But she stated: "This investigation has identified a woeful lack of communication, with uninformed and reckless decision-making regarding MAPPA (multi-agency public protection arrangements) and the management of (McLeod) during his time in and release from prison. Parts of this horrific narrative suggest statutory regulations may not have been met.
"My son can no longer play his guitar, banjo or piano two-handed, have a game of football or tennis with his friends, go running, hike, or drive. He has lost his livelihood.
"The thought that individuals took highly risky decisions that resulted in a clearly dangerous man being released unsupervised, with no known whereabouts, is almost impossible to bear.
"I believe this incident was clearly predictable and preventable. It has devastated the lives of eight people and all those who care for them; Jacob and Michael are seemingly tolerable statistics to those who resource the system."
McLeod, referred to throughout the report by the initial H, was released from HMP Parc on April 22, 2020, "subject to no restrictions or supervision" after serving a three-year sentence for drug and firearm offences.
Birmingham-born McLeod, of Nately Grove, Selly Oak, had a history of offending starting in his mid-teens and was arrested at least 21 times between 2007 and 2017. In its conclusions, the report's authors noted: "This review has concluded that H was not appropriately treated and medicated from 2011 to 2020.
"H consistently did not engage with any of the statutory services he came into contact with, from the police, prison, and probation service to local community mental health services.
"This pattern of non-engagement with services resulted in him being discharged from MAPPA in October 2019, because the panel could not see a role for itself. It also resulted in H remaining in prison until his sentence ended. The consequence was that he was released from HMP Parc in April 2020, subject to no statutory supervision from any of the criminal justice services - police or probation."
It was also noted that McLeod was released from jail to no fixed abode, so services did not know where he had gone.
The report said: "He had told services he was going to North Wales but, in reality, he returned to the Birmingham area on the day of his release." The investigation made five recommendations to improve services, including a call for the Birmingham and Solihull Mental Health Foundation Trust to develop an up-to-date operational policy covering prison discharge services.
It also recommended that the West Midlands MAPPA Strategic Management Board reconsider its decision not to complete a serious case review, which the report's authors said would be an opportunity to look in more detail at the issues it had raised.
Among other recommendations was a call to ensure the mental health in-reach team at HMP Parc has sufficient resources to meet demand. Julian Hendy, the director of the Hundred Families charity, which has been supporting relatives of Jacob Billington and Michael Callaghan said: "This is a truly shocking report. It demonstrates in very clear detail that agencies which are supposed to protect the public failed to effectively monitor a highly dangerous, violent, and seriously unwell man."
A spokesperson for Birmingham and Solihull Mental Health Foundation Trust said: "We would like to publicly express our sincere sympathies to the families and friends of Jacob and Michael.
Our chief executive and interim chief nurse met with Jo Billington and Anne Callaghan and were deeply saddened to see the terrible impact that this tragedy has had on them and their families' lives.
"As an organisation, we fully accept the recommendation in the report for us to review the service description of our discharge service. We have commissioned a comprehensive review and will update the service description accordingly, to help ensure a similar incident does not occur."
