Zoë Billingham

During Billingham's tenure, NSFT improved several indicators and services, but the CQC still rated overall leadership 'requires improvement' in October 2025, citing persistent problems of culture, leadership visibility and confidence among some employees.

State of the evidence

Documented

Attribution

Direct responsibility

As chair of the Police Remuneration Review Body, Billingham signed recommendations emphasising recruitment, retention and budgetary pressure risks within police forces while challenging an excessively narrow interpretation of affordability. The 2025 report notably stated that affordability also depended on funding decisions and criticised a police funding formula considered outdated.

State of the evidence

Documented

Attribution

Direct responsibility

Billingham was appointed to the Independent Inquiry into Grooming Gangs panel in December 2025. At the time, the inquiry was entering a phase marked by the resignation of members of a survivors' panel and two prospective chairs, amid criticism concerning the victims' voice and the inquiry's independence.

State of the evidence

Documented

Before the Home Affairs Committee in May 2026, Billingham was questioned about how the inquiry could reconstruct the historical scale of grooming gangs when national data, particularly police data, were incomplete or inconsistent. She defended a method of triangulating prosecutions, local intelligence, Beaconport data and police forces' strategic assessments.

Attribution

Directly implicated

An independent review published in 2023 concluded that NSFT lacked a sufficiently consistent and traceable mortality system to provide full assurance about its figures. The controversy intensified around a very broad death count and the trust's ability to learn systematically from patient deaths.

State of the evidence

Documented

Attribution

Direct responsibility

In 2024, further deaths prompted severe criticism of NSFT. In Christopher Sidle's case, the coroner identified missed opportunities, inadequate assessments and problems with bed availability; meanwhile, families and campaigners recorded numerous deaths associated with risks they believed had been known for years.

Attribution

Direct responsibility

An independent Grant Thornton review of NSFT's mortality data concluded that its systems were unclear, inconsistent and incomplete. The controversy concerned the trust's ability to explain several thousand unexpected deaths or deaths of patients shortly after discharge.

State of the evidence

Documented

Attribution

Direct responsibility

Following Sarah Everard's murder, the inspection led by Billingham described violence against women and girls as a national problem requiring radical, cross-cutting change, more systematic prosecution of perpetrators, consistent victim support and national priority status. The government subsequently announced its inclusion in the Strategic Policing Requirement.

State of the evidence

Documented

Attribution

Directly implicated

In August 2022, more than 140 doctors associated with the NSFT Medical Staffing Committee wrote to Billingham to denounce services they considered unsafe, recruitment difficulties and a lack of confidence in the board, requesting an urgent meeting.

State of the evidence

Documented

Attribution

Direct responsibility

The Care Quality Commission again rated Norfolk and Suffolk NHS Foundation Trust (NSFT) 'inadequate' and issued a warning, identifying safety, effectiveness and governance problems. The report also recorded 115 unexpected or potentially avoidable deaths reported between September 2019 and September 2021.

State of the evidence

Documented

Attribution

Direct responsibility

HMICFRS's assessment of police responses to domestic abuse during the pandemic found that, on average, three out of four reported offences were not pursued further by forces, with substantial variation and many forces unable adequately to explain these rates.

State of the evidence

Documented

Attribution

Directly implicated

Role of the person profiled

Protagonist not prosecuted

A joint inspection of the 2017 reforms to pre-charge bail and use of release under investigation found risks to victims, particularly the absence of protective conditions in some cases and prolonged delays. Billingham publicly criticised insufficiently anticipated consequences of the reform.

State of the evidence

Documented

Attribution

Personally implicated

Following extension of HMICFRS's remit to fire and rescue services, Billingham highlighted substantial local variations in standards, risk management and performance, describing a 'postcode lottery' in the service received by the public.

State of the evidence

Documented

Attribution

Direct responsibility

Billingham identified a serious gap in Greater Manchester Fire and Rescue Service's specialist capability to respond to certain terrorist attacks, with the region then dependent on reinforcements from Merseyside following an industrial dispute.

State of the evidence

Documented

Attribution

Directly implicated

The HMICFRS report led by Billingham found that police too often absorbed the consequences of failures or delays in mental health services, when they should be a last resort. The report called for more prevention and community-based care.

State of the evidence

Documented

Attribution

Directly implicated

Billingham publicly warned that some forces were drifting into unplanned rationing of services, with calls downgraded, investigations abandoned and a national shortage of detectives. She described the situation as potentially perilous and raised a 'red flag'.

State of the evidence

Documented

Attribution

Directly implicated

A national inspection led by Billingham concluded that most police forces needed to improve their protection of vulnerable people, including missing children, domestic abuse victims and victims of child sexual exploitation. Local inspections, notably in Nottinghamshire, identified serious delays and inadequate supervision.

State of the evidence

Documented

Attribution

Directly implicated

Under Billingham's national responsibility for domestic abuse, HMIC concluded that the priority professed by many forces was not always reflected in practice and that victims were receiving inadequate service, triggering a substantial reform programme.

State of the evidence

Documented

Attribution

Directly implicated

Billingham led a review of Essex Police's response to domestic abuse following several fatal cases. The inspection identified shortcomings in prioritisation, information, risk management and coordination with partners.

State of the evidence

Documented

Attribution

Directly implicated

As HMIC lead for inspection of police authorities, Zoë Billingham presented assessments concluding that most of those examined had not sufficiently demonstrated their ability to set priorities and achieve value for money. She called for more rigorous prioritisation as major savings were announced.

State of the evidence

Documented

Attribution

Personally implicated