Independent report

Report 4: offensive weapons homicide review - West Midlands (accessible version)

Published 21 July 2025

Name of Relevant Review Partners

West Midlands Police, Coventry City Council/Birmingham City Council – Community safety and NHS Coventry and Warwickshire Integrated Care Board CWICB

Case Reference Number:

BCSP OWHR 001

Pseudonyms:

Victim 1

Victim 2

Alleged Perpetrator 1

Date of incident which led to the Review:

April 2023

Date of death where applicable:

April 2023

Review’s start date (commissioned):

19/06/2023

Review completion date (approved and signed off):

17/10/2024

Publication date:

30/06/2025

The delays associated with the publication of this Offensive Weapon Homicide Review (OWHR) have been relatively minor and are not attributable to any specific agency or author. As this is the first OWHR commissioned by Birmingham City Council under the Offensive Weapon Homicide Review Pilot, some administrative and procedural challenges were encountered during its development.

Initial difficulties in identifying and engaging the appropriate agencies contributed to early delays; however, these challenges have offered valuable learning that will inform and improve the process for future reviews. Additionally, there were delays at the publication stage, which have since been addressed.

We appreciate the patience of all stakeholders and remain committed to transparency and continuous improvement in this important area of work.

Outline of circumstances resulting in the Review:

Chair and Membership

Independent Offensive Weapon Homicide Reviewer has been appointed as Chair of the review panel and Author of the report.

The following organisations have been nominated to sit on the panel:

Name	Organisation
Alan Critchley	Independent Reviewer/ Author
Not applicable	Birmingham    City    Council    (Community    Safety Partnership)
Not applicable	Coventry City Council
Not applicable	West Midlands Police
Not applicable	University of Coventry
Not applicable	NHS Coventry and Warwickshire Integrated Care Board

Notification

Police were called to an incident in Coventry City centre in April 2023. A stabbing had taken place with two victims, one of whom died at the scene. The other was treated in hospital and has since recovered from his injuries. The perpetrator was arrested at the scene.

An OWHR was commissioned by Birmingham City Council, Community Safety Team, on behalf of the Relevant Review Partners for the death, in accordance with the OWHR Statutory Guidance. The criteria for this Review are met under:

• Regulation 4 of the Police, Crime Sentencing and Courts Act 2022 (Offensive Weapons Homicide Reviews)

Introduction:

This review is written as part of a pilot scheme of Offensive Weapons Homicide Reviews. The relevant legislation is the Police, Crime and Sentencing Courts Act 2022. The aim of the review is to examine the causes of, mainly, knife crime and to make recommendations to reduce the incidence.

The scope of this review is quite narrow, both victim and perpetrator were Chinese nationals studying at Coventry University. Both had only been in the UK for just over six months before Victim 1 was killed by Perpetrator. Coventry University and the Police are the only relevant agencies to have had contact. The timeline is therefore short, from September 2022 to April 2023, and agency contributions are limited.

West Midlands Police and Coventry University have provided full Internal Management Reviews (IMRs). The West Midlands Police have also provided a transcript of the Judge’s Sentencing Remarks from late 2023 when Perpetrator received a sentence of 24 years for the murder of Victim 1 and a concurrent sentence of 8 years for the wounding of another young man in the same incident, Victim 2.

West Midlands Police and Coventry University are commended for their open engagement with this review.

Victim 1 and Perpetrator did not, as far as is known, know each other prior to their arrival in the UK, they came from difference provinces.

The review group is wider than the immediate agencies involved. This provides proper scrutiny to the process and the review. The author of this review is a Social Worker with experience of writing Safeguarding Adult Reviews and Domestic Homicide Reviews.

Victim 1 was aged 22 when he died. Information about Victim 1 himself has come from the Family Liaison Officer, West Midlands Police and from the Victim Impact Statement from his family that was read out in court when Perpetrator was sentenced.

Victim 1 was by all accounts bright and ambitious. He had come to the UK to further his ambitions and he had, no doubt, a bright future ahead of him. He was also a devoted son who spoke to his family in China every day. His parents and his younger sister have been devastated by his loss and the thoughts of all those involved in this review are with them. As his parents said in the Victim Impact Statement:

He travelled across the ocean, and far, far away from home, to England in order to study and receive a better education. He worked very hard. He was the only hope, the life and soul of our family.

Equality and Diversity

Both victims and the perpetrator were of Chinese heritage. Whether this protected characteristic was relevant to the review was discussed with the Review Group on 24th October 2023. The view of the group was that Chinese nationality gave no known links or relevance to the circumstances of this review.

No other protected characteristics are considered relevant to this review.

Age of victim; 22

Disability of victim; None known

Gender reassignment; Not applicable

Marriage and civil partnership; Not applicable

Pregnancy and maternity; Not applicable

Race ; Chinese

Religion or belief; Not known

Sex; Male

Sexual orientation; Not applicable

Socio-economic disadvantage; No factors identified

Involvement of family/next of kin and other relevant persons:

The issue of whether Victim 1’s family might be involved in this review was discussed in the Core Group. The review author also discussed it with the Family Liaison Officer. The consensus view was that no attempt would be made to seek the views and thoughts of the family in China. This was because of their level of distress, the language difficulties and the geographical separation. The Victim Impact Statement presented to the sentencing court spoke of Victim 1’s parents both having had heart attacks in the aftermath of their loss and that their daughter had stopped going to school. The deep distress had, understandably, extended to the wider family. Whilst any review should seek to obtain family input the judgement of the author of this review and those associated with it was that contacting the family might cause more hurt than could be readily managed given the distance and language. Some of their thoughts and experiences have been relayed by the Family Liaison Officer and are included below. The Family Liaison Officer explained that Victim 1’s family were “living their dreams” through their son, he was bright, studying internationally and had a good future ahead of him. They are not a wealthy family and finding the money for their son to come to the UK was hard. Throughout his time in the UK he had rung them daily, keeping them in touch with his progress. Understandably, the family were absolutely devastated by his death. His mother particularly found it hard and, at one stage whilst in the UK, had to attend hospital due to her emotional distress. The family are concerned that the perpetrator will be returned to China at some point, they don’t want this to happen. They were also concerned that he had not, as might have happened in China, received the death penalty. This comment is included for context and should not be read as a review finding. The second victim in the incident was contacted and was asked whether he wished to take part in the review. It was explained to him that his thoughts would be valued, and helpful for the review, but that there was no pressure on him to participate. He has not responded.

Contact with the Alleged Perpetrator’s Family

See text for details. Comments about the victim’s family are applicable to the perpetrator’s family.

Agency Timeline:

Perpetrator and Victim 1 had very little contact with anyone in the UK apart from their student colleagues at the university, who were also Chinese. The university said that both were excellent students with a very good attendance record.

Victim 1 enrolled on 13th September 2022 to study Accounting and Finance for the International Business Top-Up course. This would have awarded him a degree from Coventry University when added to his previous studies. He had no engagement with the disciplinary, appeals or complaints team; meaning that he kept out of trouble.

Perpetrator enrolled with the university on 22nd September 2022, also on an International Business Course.

Perpetrator’s offending is described more fully below but the relevant dates are:

• October 2022- Threaten with bladed article.
• January 2023- Potential assault, victim unconfirmed,
• April 2023- Homicide committed.

Perpetrator had registered with a GP on 28th September 2022. He attended the surgery on 28th October 2022 complaining of dizziness following an assault on 25th October, he said that he had reported this to the police. Given the limited contact there is nothing more of relevance from the GP surgery and no expectation that they might have done more.

Improving Systems and Practice (National, Regional and Local):

Over his short time in the UK Perpetrator had begun to build up a history of offending. Of most note is that he was involved in an incident in October 2022, some five weeks after his arrival in the UK. At 04.30 in a street in the centre of Coventry he threatened someone with a bladed article, this was a half pair of scissors. He had pointed the blade at the victim’s chest. Perpetrator said that he had been to a friend’s house for a “few drinks”, it was not recorded that he was intoxicated. His claim was that he had had his phone stolen and that he was trying to retrieve it. The Independent Management Review from West Midlands Police says of the incident, “P admitted to carrying scissors……in the light of the admission, lack of any previous convictions/cautions for any offences and the lack of complaint from the victim, P was issued with a simple adult caution”. The view of the author of this review is that this conclusion doesn’t stand scrutiny or take risk into account. In terms of potential dangerousness, the lack of complaint from the victim is irrelevant. Given Perpetrator’s birth overseas and recent arrival in the UK it was unsafe to assume that he had no previous convictions. Most importantly though, he had fashioned a dangerous weapon by halving the scissors and he was carrying it, one can assume with the thought, if not the explicit intention, of using it. This is exactly what happened in April 2023 when he returned home to get the weapons with fatal results. He had also been drinking on both occasions. If the matter from October 2022 had been taken to prosecution, possession of an offensive weapon and making a threat, the relevant sentencing guideline gives a range of three months to three years custody. This review was told that West Midlands Police have liaison officers who work with Coventry University. The University could, and should, have been told of the offence in October 2022. “Public Interest” overrides GDPR (General Data Protection Regulation) in these instances. The University explained to this review that when a student is alleged to have committed an offence, they undertake a risk assessment to determine whether the allegation makes them a risk to the university, community, staff, students and any other members of the public. Dependent upon the circumstances the university can take precautionary action pending the outcome of any investigation. If this had included withdrawing Perpetrator from his studies the Home Office would have been informed and this might have impacted upon his visa. Over his time in the UK Perpetrator had a further incident that brought him to the attention of the police. In January 2023 he was reported as acting aggressively to staff in a club. Officers attended and found him slumped over a toilet in an intoxicated state. He was initially abusive to officers but calmed down and returned to his student accommodation. No further investigation followed. The University should also have been informed of this incident. Put together these incidents were indicative of significant risk. The author of this review had hoped to see Perpetrator in prison to discuss the homicide with him and to learn of his thoughts on how it might have been averted. He has however been advised by his solicitor not to discuss the offence pending appeal against sentence and he has therefore not felt able to contribute to this review. He has said that he would like to share his thoughts after the appeal and the author of this review has agreed to see him, albeit that is likely to be after the review is finalised and published. He did however say to his probation officer in prison that he felt frightened in Coventry and he became quite emotional whilst discussing this. His behaviour in prison has been exemplary and, in the words of his probation officer, he “stands out like a sore thumb” from the other prisoners in the category A prison he is accommodated in at the time of writing this. In October 2022 Perpetrator had a bladed article on him, in April 2023 he returned home for a bladed article. Although he has not said it directly to this review, the fact that Perpetrator felt frightened when he was out in Coventry, as relayed to the prison Probation Officer, may have been a contributing factor to his carrying a weapon. Logic would say that this would never be purely defensive, if someone is carrying a weapon, they are probably prepared to use it. Especially when alcohol is involved. In both instances, October 2022 and April 2023 Perpetrator had modified the scissors into an offensive weapon and carried it with him. Likely, with the intention that he would use it. The College of Policing sets out reasons why people might carry knives^{[footnote 1]}. Perpetrator was a-typical in that he was older and better educated that some groups mentioned. However, self-protection and fear (‘defensive weapon carrying’) – particularly for individuals who have previously been a victim of crime^{[footnote 2]} may be relevant in this instance. This review understands that fear of crime in China is low and the core group were told that a laptop could be left in a café in China with some confidence that it would still be there when the owner returned. Whilst this is anecdotal it is likely to have some resonance for students from China who may well have experienced the fear of crime in the UK.

Learning Points

1) The circumstances of this review are highly unusual and will, hopefully, not exactly be repeated. There is, however, some learning from the tragic death of Victim 1 that has wider applicability.

2) Although little is known of Perpetrator prior to his arrival in this country it is worth noting, and this may apply to anyone about whom little is known, that his temper escalated rapidly to the point where he was capable of homicide. Having been seen to be, apparently, out of control, he then returned calmly to his home, gathered the weapons and then killed Victim 1 in a planned and considered way. Alcohol played a significant role. Perpetrator 1’s actions are a reminder that relatively normal scenarios involving lightly convicted people can, and do, end in tragedy.

3) An adult Caution was not an appropriate response to Perpetrator 1’s arrest in October 2022 for carrying an offensive weapon. This review understands that the West Midlands Police would now have acted in a different way. Policy with regard to knife crime means that Cautions will be unusual. Where, due to exceptional circumstances Cautions are administered it should always be conditional on completing knife crime education awareness course. Failure to complete such a course will result in a return to the Criminal Justice system.

4) If Perpetrator 1 had been prosecuted he would have moved into the criminal justice system. This would have likely have resulted in the termination of his course and his return to China.

5) If Coventry University had been made aware of the growing risk of Perpetrator 1 from October 2022 onwards, they could have terminated his course.

6) Coventry University to consider whether they are doing enough to directly address the fear of crime and how students respond. This may be of relevance to other universities.

7) West Midlands Police should review the circumstances under which they failed to tell Coventry University of the risk posed by Perpetrator 1 and should provide assurance to the Community Safety Panel that the same circumstances could not be repeated.

Dissemination

List of recipients who will receive copies of the Review Report (in line with guidance and due to the recommendations of this Report): Please copy and paste the appropriate number of instances.

Date circulated to relevant policy leads: 04/01/2025

Organisation	Yes	No	Reason
Single Competent Authority	☒	☐	Click or tap here to enter text.
West Midlands Police	☒	☐	Click or tap here to enter text.
NHS Birmingham and Solihull Trust/ Sandwell and Birmingham NHS Trust	☒	☐	Click or tap here to enter text.
Change Grow Live	☒	☐	Click or tap here to enter text.
Birmingham City Housing/ Sustain Housing	☒	☐	Click or tap here to enter text.

OWHR process

IMRs were requested from West Midlands Police and Coventry University. These were provided in a timely way. Three meetings of the Core Group were held, to agree terms of reference, an early draft of the review and a final draft. Final quality control was provided by an Oversight Board in the West Midlands.

Final confidence check

This Report has been checked to ensure that the OWHR process has been followed correctly and the Report completed as set out in the statutory guidance.

I can confirm that this Report section is at a standard ready for publication ☒

Once completed this report needs to be sent to the Secretary of State for the Home Office. Tick to confirm this has been completed. ☐☒

Statements of Independence

Statement of Independence by Chair:

Please read and sign the following statement. Consider the section on independence in the OWHR Statutory Guidance before completing.

Chair : Alan Critchley

Statement of independence from the case

I make the following statement that prior to my involvement with this review:

• I have not been directly involved in the case or any management or oversight of the case.
• I have the appropriate recognised knowledge, experience and training to undertake the review. Therefore, I have met the criteria of an Independent Chair.
• The review was conducted appropriately and was rigorous in its analysis and evaluation of the issues as set out in the Terms of Reference. I recognise that the purpose of this is to identify learning from the case, not to attribute blame to practitioners or agencies.
• I have read and understood the equality and diversity considerations and will apply accordingly.

Please set out below how you meet paragraphs 3.14 – 3.19 of the OWHR guidance

The Independent SAR Chair of the Panel, who is also the Overview Report writer, is a safeguarding consultant. He is a qualified Social Worker. He has held a number of safeguarding roles and was, from 2015 to 2018, the Independent Chair of the Walsall Safeguarding Children and Adults Board. He provided the safeguarding expertise into a review of safeguarding failures at the Royal National Institute for the Blind (publ. Charity Commission 2020) and is the Independent Safeguarding Chair for Dimensions UK. Since leaving his role in Walsall in 2018 he has had no contact with agencies in the West Midlands, apart from Chairing this review. He is therefore independent of all agencies and people involved in this review.

Signature: Alan Critchley

Name:* Alan Critchley

Date: 17/10/2024

To be completed by the Home Office:

Please tick here to confirm that the Chair was appointed from the Independent Chairs List held by the Home Office: ☒

Scope/Terms of Reference

• To undertake a review into the death by stabbing of SK using the methodology of an Offensive Weapons Homicide Review (Police, Crimes, Sentencing and Courts Act 2022).
• The review to be complete, to the satisfaction of the local review partners, by end December 2023. Changes to timescale to be agreed with the statutory partners.
• To provide recommendations for improving systems and practice as a result of learning from the death of SZ.
• To set out, and comment on, any relevant protected characteristics
• Assess and analyse the role of alcohol in the homicide and also in the event in October 2022 for which a caution was given.
• To provide comment and reflection on the adult caution received by PS in October 2022. In particular to comment on whether the adult caution was an appropriate outcome and what alternatives there were.
• Was the incident in January 2023 when SZ was, apparently, drunk and pushed someone down some stairs appropriately managed? Were there any missed opportunities for intervention in this incident and the one above?
• The timeline of the review will be from the arrival of SZ in this country on 9th September 2022 through to his death. The provision being that this may be extended if there is any relevant information obtained by this review prior to SZ’s arrival.
• To establish what checks were undertaken on SP prior to his arrival in this country by a) UK Visas and Immigration and b) Coventry University.
• To establish what was undertaken by Coventry University as induction to the area. In particular on safety and staying safe. Did the university set out any expectations of behaviour?
• Comment on any violence that that SP might have been subject to and the “fear” that, he said, led him to carry a weapon. To set out the circumstances of the death of SZ.
• Provide context and understanding of the death of SZ (why it happened)
• Set out learning from the death of SZ, being clear who the learning is applicable to.

1. https://www.college.police.uk/guidance/knife-crime-evidence-briefing/understanding-causes-knife-crime. ↩

2. Lemos, 2004 pdf. ↩