MENTAL health provision at HMP Hewell has been criticised in a report investigating how a former prisoner and paranoid schizophrenic slipped through the system to stab a schoolgirl to death.

Despite a long history of violence and HMP Hewell staff recommending Phillip Simelane be detained in a secure psychiatric unit, the 25-year-old was allowed to roam the streets to kill Christina Edkins last March.

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

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 report made a number of recommendations to the Tardebigge prison and Worcestershire Health and NHS Care Trust (which provides care in the prison) to improve mental health provision, internal and external communications and improve relationships with other agencies including prisoners' GPs.

Michael Spurr, chief executive officer of the National Offender Management Service, which is responsible for HMP Hewell said: "Our thoughts are with Christina's family and friends at this time.

"All agencies involved, including the prison service and our NHS partners are committed to learning lessons from this tragic incident and we will carefully consider the recommendations, working with our healthcare partners."

However, the report did praise staff at HMP Hewell for flagging up Simelane's illness and efforts to warn HMP Birmingham and Birmingham and Solihull Mental Health Trust about his condition.

The report stated: "The forensic specialist registrar at HMP Hewell confidently diagnosed Simelane as mentally unwell and was persistent in pursuing a healthcare treatment environment for him, despite other health professionals disagreeing with his opinion."

Tragically the warnings were ignored and Simelane was released from HMP Birmingham without mental health supervision in December 2012.

He fatally stabbed 16-year-old Christina on March 7, 2013, on the number nine bus as she made her way to school.

Simelane, aged 25, was subsequently convicted of manslaughter on the grounds of diminished responsibility and was detained without a time limit in a secure psychiatric hospital.

Reacting to the investigation Christina Edkins' family representative said: "We believe that it was predictable that, without treatment, Phillip Simelane would eventually resort to a knife attack on another person and it was only a matter of time before he carried out his threats to kill."

The full report can be found at bhamcrosscityccg.nhs.uk.

The HMP Hewell Healthcare recommendations in full:

1. HMP Hewell (Healthcare) should ensure that when the GP is known that the information is recorded appropriately on Systm1 and noted on the IMR main demographic record.

2. HMP Hewell (Healthcare) should ensure a review of the process of healthcare assessment prior to release to ensure relevant healthcare information, which may have been found during detention, is identified.

3. HMP Hewell (Healthcare) should ensure that whenever possible a summary of the individual’s Prison health records is provided to their GP on release from Prison.

4. HMP Hewell (Healthcare & Prison) should ensure that in all cases where there are concerns in respect to a prisoner not having the necessary capacity to make a significant decision, that the guidance outlined within the Mental Capacity Act is enacted and that a Best Interest decision is made. This should be recorded, maintained and shared as appropriate to Courts and other services.

5. HMP Hewell (Healthcare) should ensure that robust systems are in place for assessing, managing and communicating all known physical and mental health concerns at admission, transfer and release from Prison.

6. HMP Hewell should ensure that there is a robust system in place for recording letters to the Governor, which relate to the health, clinical risk assessment or wellbeing of a named Prisoner, and that a record of such communication is placed within the relevant Systm1 healthcare records.

7. HMP Hewell should give consideration to the development of a recording or log system for concerns raised by relatives to the Prison Chaplain.

8. HMP Hewell (Healthcare) should review the local arrangements for requesting and managing physical and mental healthcare referrals and clarify roles and responsibilities, record keeping system for production of correspondence, including administrative staff support, monitoring of timeliness of responses, noting and confirming follow-up arrangements and  processes for escalating concerns

9. HMP Hewell (Healthcare) should review the local arrangements for release of Prisoners with physical and/or mental healthcare needs, where there are significant concerns that an individual is likely to deteriorate on release, such as due to non-compliance. In such cases, as good practice, such concerns should be shared with the individual’s GP whenever possible.

10. HMP Hewell (Healthcare) should ensure health screening on discharge includes reference and cross-checking between health and prison records systems.

11. In all cases where HMP Hewell has significant concerns at the time of release as to an individual’s mental health and wellbeing, HMP Hewell (Healthcare) must ensure that appropriate consideration is given to undertaking an urgent assessment under the Mental  Health Act 1983 (as amended 2007) and that a written record is maintained to this effect.