A SHOCKING investigation report into the events leading up to the murder of Halesowen schoolgirl Christina Edkins has revealed her tragic death could have been avoided if the killer had received better mental health care.

A litany of mistakes or oversights by several agencies including the NHS, Birmingham and Solihull Mental Health Trust, HMP Birmingham, HMP Hewell, the National Offender Management Service andWest Midlands Police were revealed in the report published today (Monday).

Christina's killer Phillip Simelane had been known to several agencies for a number of years after his mother pleaded for help concerning his mental health problems.

After getting on the number 9 bus with an out of date ticket on March 7 last year he stabbed the school girl fatally as she travelled to Leasowes High School.

The paranoid schizophrenic was subsequently convicted of manslaughter on the grounds of diminished responsibility and was detained without a time limit in a secure psychiatric hospital.

The investigation was co-ordinated and published by Birmingham Cross City Clinical Commissioning Group (CCG) and 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 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."

She added: “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 Simelane mother to secure help for her son."

She added: “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 Simelane'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 Cross City CCG added: “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.

A number of recommendations have already been implemented, including a centralised process is in place to ensure that all clinical correspondence related to mental health is maintained appropriately, and correspondence can be accessed in the clinical records.

And an escalation/resolution process in case of disputes or concerns following a prison-based mental health assessment.

Also new guidelines and protocols for assessments - covering issues of training, supervision, clinical audit, information-sharing and record-keeping - have been implemented.