The findings of an independent investigation into the care given to the killer of a 16-year-old schoolgirl will be published by the NHS today.
Publication of the report by NHS England comes three years after a separate homicide review said Christina Edkins' death at the hands of Phillip Simelane followed a series of "mismanaged opportunities'" to identify his acute psychotic disorder.
The previous inquiry also found the death of Christina, from Birmingham, could have been prevented if her killer had received appropriate treatment.
Simelane, from Walsall, pleaded guilty to manslaughter following the random stabbing on a bus in Birmingham in March 2013, and was detained indefinitely under the Mental Health Act.
Published in September 2014, the multi-agency investigation into the killing, co-ordinated by NHS Birmingham CrossCity Clinical Commissioning Group, highlighted long-term failings by members of the police, prison service and medical staff.
Commenting on the report's findings, its chair Dr Alison Reed said: “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's) mother to secure help for her son.
“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.”
The report's authors made 51 recommendations to seven agencies involved in the case for changes to processes, practices and partnership-working.
The NHS announced a second inquiry into the care given to Simelane in November 2014 after the initial report was reviewed by an independent committee.