DOZENS of opportunities were missed to get more mental health intervention for a former HMP Hewell prisoner who stabbed a schoolgirl to death on a bus.
A report released by Birmingham Cross City Clinical Commissioning Group revealed Philip Simelane, who is now in a secure unit after admitting manslaughter with diminished responsibility following the death of 16-year-old Christina Edkins in Birmingham in March last year, had 17 assessments including four at the Tardebigge prison.
He started his sentence in July 2012 for an unrelated offence and was cared for by Worcestershire Health and Care Trust, which is responsible for healthcare at HMP Hewell. Simelane was prescribed anti-psychotic medication for paranoid psychosis and referred to Birmingham and Solihull Mental Health NHS Foundation Trust ahead of his release in October that year but did not meet their criteria for hospital admission.
Following his release from Hewell on license, his GP was not notified he had been prescribed the medication or that he was out of prison and there was no mental health follow up.
He served a further sentence at HMP Birmingham from October to December 2012. It is believed he was sleeping rough between that time and his arrest in March for Christina’s death.
The report makes a number of suggestions regarding changes which should happen at HMP Hewell, including a summary of prisoner’s health records being given to their GP on their release and robust systems being put in place for assessing and communicating all known physical and mental health concerns at admission, transfer and release from prison.
The Trust should also consider an urgent assessment under the Mental Health Act where there are significant concerns about an inmate’s mental health and wellbeing when they are released.
Sarah Dugan, chief executive of Worcestershire Health and Care NHS Trust, said: “The Trust extends its sympathies to Christina’s family and appreciates how important it is to them that actions are taken following this tragic event.
“The Trust has fully supported the review into the circumstances surrounding Christina’s death. We are addressing the recommendations that have been made in relation to the services provided by the healthcare department at HMP Hewell in conjunction with the prison authorities.”
John Short, the Birmingham Trust’s chief executive, said it was an ‘extremely distressing case’.
“We fully accept the review’s findings and acknowledge that we must learn from what happened. The review panel has confirmed Christina’s death could not have been predicted, but it was preventable because had there been intervention to address P’s mental health needs, there may have been a different outcome.”
He added the Trust had led a comprehensive review and were already addressing the recommendations in the report.
