Independent investigation into the mental health care of Nottingham attacker published

An independent investigation into the NHS Mental Health Trust's care of the man who attacked and killed three people in Nottingham in 2023, has been published today.

Valdo Calocane was not forced to have long-lasting antipsychotic medication because he did not like needles, a report has revealed.

Other patients cared for by the mental health trust involved with Calocane's treatment also committed "extremely serious" acts of violence including stabbings, between 2019 and 2023, investigators found.

Calocane, who had been diagnosed with paranoid schizophrenia, was sentenced to an indefinite hospital order after killing 19-year-old students Barnaby Webber and Grace O'Malley-Kumar, and 65-year-old caretaker Ian Coates, before attempting to kill three other people, in a spate of attacks in Nottingham in June 2023.

The independent review highlighted how, in one assessment carried out by mental health workers, the risk to staff was "managed" by making arrangements for workers not to visit Calocane's home alone, but a plan for the "hazards" if he came off his medication and disengaged with mental health services was not developed.

The report detailed two years of violent and disturbing behaviour including frightening a neighbour so much they jumped out of a first floor window, leading to a serious back injury, punching a police officer in the face and holding his flatmates "hostage".

NHS England commissioned Theemis Consulting to carry out an independent investigation into the care and treatment provided to Calocane by NHS services.

It revealed he had four hospital admissions between 2020 and 2022 and multiple contacts with community teams before he was discharged to his GP because of a lack of interaction with mental health services.

Investigators found that the offer of care and treatment available for Calocane was "not always sufficient to meet his needs" and this was "not unique" to his case.

Health officials have admitted it is "clear the system got it wrong".

Across the NHS in England mental health services have been ordered not to discharge people if they do not attend appointments.

A number of criticisms were highlighted in the review, including:

• Requests were made for Calocane to be put on a community treatment order which would have permitted him to be put on depot medication.
• Risk was "was not fully understood, managed, documented or communicated".
• Each hospital admission was seen in isolation with a "lack of cumulative perspective" over how Calocane appeared to engage in hospital but not when he was at home.
• The way he was discharged from community services back to his GP due to "non-engagement". The authors said a lack of engagement had become an "accepted reason for discharge" and "normalised", adding: "Discharge in the absence of a face-to-face meeting with a patient creates the potential for greater risk to the person using mental health services and to others."
• How high workload could have contributed to his discharge to GP services in . At the time his care co-ordinator had an average caseload of 20 service users - five above the limit advised by leading psychiatrists.

Dr Jessica Sokolov, regional medical director at NHS England, Midlands, said:

"It's clear the system got it wrong, including the NHS, and the consequences of when this happens can be devastating.

"This is not acceptable, and I unreservedly apologise to the families of victims on behalf of the NHS and the organisations involved in delivering care to Valdo Calocane before this incident took place."

Claire Murdoch, NHS England's national mental health director, added:

"It is clear there were failings in the care provided to Valdo Calocane which is why the trust responsible was placed in our highest oversight and support programme, which has seen them overhaul their risk assessment processes.

"Nationally, we have asked every mental health trust to review these findings and set out action plans for how they treat and engage with people who have a serious mental illness, including how they work with other agencies such as the police.

"And we've instructed trusts not to discharge people if they do not attend appointments.

"We are determined to do everything possible to transform how the NHS treats people with a serious mental illness who often require long-term support."

The document detailed a number of incidents involving patients linked to Nottinghamshire Healthcare NHS Foundation Trust.

"Between 2019 and 2023 there were 15 incidents of patients either under the current care of the trust or who had been discharged from the trust, perpetrating serious violence towards members of the community," the report said.

While some of the victims were known to perpetrators, in some incidents the victims "appeared to be strangers".

"The level of violence in the incidents was extremely serious and in three cases resulted in fatalities," the report said.

"The majority of these incidents involved stabbings.

"Most notably, in February 2023 there was an incident where a patient in receipt of mental health services from Nottingham Healthcare NHS Trust was arrested for stabbing five people over the course of a weekend."

The review team looked to see if these incidents had been discussed by the trust board but found "limited evidence regarding discussions of these particular serious incidents or subsequent investigations".

The authors also said that Calocane's "concordance with medication was in question shortly after each discharge from hospital".

Depot medication was discussed a number of times but the report said: "The inpatient teams involved in VC's care were trying to treat VC in the least restrictive way and took on board VC's reasons for not wanting to take depot medication which included him not liking needles."

The report added: "A theme running through VC's clinical records is that he did not consider himself to have a mental health condition.

"His insight into his condition did not appear to increase and therefore his understanding of the importance of medication in his case never appeared to be understood by VC."

It said this "may have meant that he lacked full capacity" to make decisions about his care and treatments.

The report also highlighted how Calocane's family were concerned his second hospital admission was only two weeks long and such a short stay was a "missed opportunity to fully understand VC's diagnosis, risk and to get to grips with a treatment plan".

Investigators said NHS England should examine the "dissonance between what people think should be happening, for example, care described in national policies and guidance, compared to what is actually being delivered in some services".

Recommendations have also been set out for the trust, including enhancing family engagement, care planning and information sharing.

NHS officials published the report in full after initially saying they would only publish a summary due to data protection issues.

The trust has been approached for comment.

33 year-old Valdo Calocane serving an indefinite hospital order

On June 13th 2023, Calocane fatally stabbed two 19-year-old university students as they were walking home from a night out - before he went on to stab a school caretaker, also taking his van and knocking down three pedestrians.

He killed Grace O'Malley-Kumar, Barnaby Webber, and Ian Coates that day.

In court, prosecutors called the attack 'uncompromisingly brutal', and he was sentenced to an indefinite hospital order in January 2024, after admitting the manslaughter by reason of diminished responsibility - and the attempted murder of three others.

Calocane's sentencing hearing was told that multiple medical experts concluded he had paranoid schizophrenia, with the court hearing he had several interactions with mental health services in the months before the attacks.

His sentence by Mr Justice Turner also made it clear he will be subject to further restrictions if he is ever discharged, which must be approved by the Justice Secretary.

The sentence was referred to the Court of Appeal by the Attorney General, but senior judges later ruled the punishment wasn't "unduly lenient".

CQC report finds opportunities missed by Nottinghamshire's health services

In August last year the final part of a special Care Quality Commission review into the care of Calocane by Nottinghamshire Healthcare NHS Foundation Trust (NHFT) found risk assessments "minimised or omitted" key details of the serious risk he posed to others.

It was commissioned by the Rt Hon Victoria Atkins MP, the former Secretary of State for Health and Social Care.

The report also found "poor decision-making, omissions and errors of judgments" meant he did not receive the follow-up care needed.

The Care Quality Commission (CQC) said the evidence “indicated beyond any real doubt” that Calocane would relapse “into distressing symptoms and potentially aggressive behaviour”.

It also questioned how well the trust engaged with Calocane's family, who raised concerns about his mental state.

Public Inquiry will be held into Nottingham attacks.

A statement from the families, issued at a similar time to the final publication of the rapid review into the Nottinghamshire Healthcare NHS Foundation Trust, by the CQC, revealed they have had confirmation that a public inquiry will take place, to examine the events which led to Calocane's actions, after meeting Health Secretary Wes Streeting and Attorney General Richard Hermer.

It said: "The final form of the inquiry is yet to be determined, but we families urge that it must be a statutory, judge-led one."

It is understood that Prime Minister Sir Keir Starmer remains committed to a judge-led inquiry into the case.

Other investigations and findings have also been released since the attacks in 2023, including when the families of Grace, Barnaby and Ian learned they could've been "better supported" during Valdo Calocane's trial, following a review of the Crown Prosecution Service's actions.

Anthony Rogers, chief inspector of His Majesty's Crown Prosecution Service Inspectorate (HMCPSI), also called on the Government to "to consider amending the homicide law, review the support provided to victims of crime in serious cases such as this, and provide greater clarity about the role of victims in the criminal justice system."

Nottinghamshire Police were also placed into special measures and told to "urgently produce an improvement plan" by a watchdog - though a watchdog spokeswoman said it was not related to the force's handling of Calocane.

June 13th 2024 - one year on

Last year a vigil was held in the city to remember the 19 year olds Grace O'Malley-Kumar, and Barnaby Webber, as well as caretaker Ian Coates who was 65 years old.

A two minute silence was held at Nottingham University's Park Campus, followed by speeches from Vice Chancellor Professor Shearer West and the university Chaplain, Grant Walton.

Grace and Barney were students at there, having just completed their first year of studying when they were killed.

In the days and weeks that followed that attacks, vigils were held both in Old Market Square and at the University in memory of the victims, with thousands of people attending.

Flowers were also placed by fellow students and relatives in Ilkeston Road, where Barnaby and Grace were attacked.

Grace's father, Dr Sanjoy Kumar, told the memorial service she had chosen "friendship over fear" and "fought valiantly" to protect her friend.

Pupils at Nottingham's Huntingdon Academy, where Nottingham Forest fan Mr Coates worked, were also invited to wear red to remember him.

In a joint statement issued before the service, relatives of all three victims said they would take time to remember "the souls of the three vibrant, caring, hard-working and much loved family members who are no longer here".

What happened in Nottingham on June 13th:

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