A homicide investigation report into the events leading up to the murder of Christina Edkins in March 2013 has highlighted the opportunities missed by a number of agencies that could have prevented her death.
The investigation co-ordinated and published by Birmingham CrossCity Clinical Commissioning Group (CCG) calls for the improved sharing of mental health information between agencies and greater co-operation between organisations involved in an individual’s mental health care.
The report highlights the fact that often people with mental health issues are not always able to access appropriate medical support and raises concerns that repeated requests for help from the perpetrator’s mother went unheeded by a number of agencies and professionals.
Christina Edkins died on 7 March 2013 following an unprovoked attack on a bus travelling through Birmingham. The perpetrator ‘P’ was subsequently convicted of manslaughter on the grounds of diminished responsibility and was detained without a time limit in a secure psychiatric hospital.
The report’s findings include:
- Organisations failed to listen to and respond to carers and significant others consistently and adequately
- The accessing and sharing of information between key agencies was ineffective
- Organisations’ information recording and storage were not robust enough to allow good management and care
- Services need to be more proactive in making it easier for a person with mental health issues to engage with them
The investigation report has been produced by a panel of experts using a similar approach to a serious case review to explore key issues and areas for learning.
The chair of the investigation panel, Dr Alison Reed said: “Throughout this review, the families involved have been uppermost in our thoughts. We have been determined to address their concerns and there has been a commitment from the outset to publish our report, which we have already shared with the families.
“Many different organisations are associated with this very sad and complex case. Therefore it is right that this has been a multi-agency review, with senior representation from child protection and the criminal justice system as well as the NHS.
“We have endeavoured to be thorough in identifying learning for all concerned. It is clear that there were missed opportunities, particularly for organisations and professionals to work together more closely in heeding the repeated attempts by P's mother to secure help for her son.
“The attack on Christina was random and unprovoked and therefore it could not have been predicted. However, it is the conclusion of the panel that as Christina's death was directly related to P's mental illness, it could have been prevented if his mental health needs had been identified and met.
“While it is impossible to remove risk entirely, we sincerely hope that our recommendations will help to reduce such risk in future.”
Dr Gavin Ralston, Chair of Birmingham CrossCity CCG said: “My heart goes out to the families, friends and relatives whose lives will have been devastated by this terrible event. We coordinated the commissioning of this report so that all the agencies involved can learn from what happened and take action to avoid this happening again. I thank the investigation panel for its work and I strongly urge all the organisations involved to complete their implementation of the recommendations as soon as possible.”
The review makes 51 recommendations for changes to processes, practices and partnership- working for seven agencies across the West Midlands as well as six national bodies. The local Adult and Children’s Safeguarding Boards both have a role in monitoring the actions arising from this report and for holding the individual organisations to account.
A number of recommendations have already been implemented, namely:
- a centralised process is in place to ensure that all clinical correspondence related to mental health is maintained appropriately, and that such clinical correspondence can be accessed in the clinical records
- an escalation/resolution process in case of disputes or concerns following a prison –based mental health assessment
- new guidelines and protocols for assessments - covering issues of training, supervision, clinical audit, information-sharing and record-keeping