Inquest into Jacob Billington’s death concludes

8 March 2024

The inquest into the death of Jacob Billington, who was stabbed to death in Birmingham city centre in September 2020, concluded on 8 March 2024.

Jacob Billington was 23 years old when he was stabbed to death in a knife attack. The perpetrator – Zephaniah McLeod – was a paranoid schizophrenic with a lengthy criminal history. Mr Billington was one of eight individuals attacked at random by McLeod on the night of 5-6 September 2020. In a trial in 2021 McLeod was sentenced for the manslaughter of Mr Billington, the attempted murder of four others and for causing grievous bodily harm with intent in respect of three more.

Until April 2020 McLeod had been in prison. He had reached the end of his sentence (having previously been recalled when released on licence). In October 2019 he had been discharged from oversight by the multi-agency public protection arrangements (MAPPA) due to his persistent lack of engagement with the prison, probation and mental health services.

The inquest examined, amongst other matters:

  • How information was shared when McLeod moved prisons and whether there was adequate information sharing to ensure effective risk management.
  • Whether McLeod’s use of medication was appropriately monitored and whether there was an adequate response to him not taking his medication.
  • How mental health information was shared between providers and whether this was adequate and whether appropriate risk assessments were undertaken.Whether there was adequate assessment of McLeod’s risk to others and whether sufficient steps were taken to address those risks.
  • Whether the MAPPA process was effective and whether the correct information was provided to inform decision making.
  • How McLeod’s release from prison in April 2020 was managed and whether it was sufficient management of his risk.
  • The circumstances leading to Mr Billington’s death on 6 September 2020, including the police response.

The Senior Coroner for Birmingham and Solihull concluded that Mr Billington was unlawfully killed. Additionally, she found that there were multiple failures in the management and treatment of McLeod’s mental health conditions. The Coroner concluded that McLeod’s discharge from MAPPA was flawed. She criticised the lack of effective resettlement planning prior to McLeod’s release from custody.

The Coroner indicated that she would be writing a report to prevent future deaths raising concerns as to (i) the management of the release of prisoners and inter-agency working; (ii) SystmOne; (iii) the lack of provisions or guidance when high risk individuals are released at their sentence end date; and (iv) a lack of clarity as to the role and functions of prison discharge coordinators.

Jonathan Dixey acted for the Chief Constable of West Midlands Police.

Other interested persons in the inquest included G4S Care and Justice (UK) Limited, the National Probation Service, the Birmingham and Solihull Mental Health NHS Foundation Trust and Swansea Bay University Health Board.

The inquest was widely reported in the national media: BBC; Sky News; ITV.


Jonathan Dixey

Call 2007

Related areas

Police Law


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