Nottingham attacks: report finds errors in mental health care
The CQC report is out at the same time as it's being confirmed a public inquiry into the attacks will go ahead
Last updated 13th Aug 2024
A new report into the care Nottingham attacker Valdo Calocane received from his local mental health trust has found "poor decision-making, omissions and errors of judgments" which meant he did not receive the follow-up care needed.
The report highlights how he was discharged back to his GP in September 2022.
But the Care Quality Commission (CQC) said the evidence “indicated beyond any real doubt” that Calocane would relapse “into distressing symptoms and potentially aggressive behaviour” and the decision to send him back to GP care “did not adequately consider or mitigate the risks of relapse”.
Calocane stabbed 19-year-old students Barnaby Webber and Grace O'Malley-Kumar as they returned from a night out in the early hours of June 13 last year, before killing 65-year-old Ian Coates.
Public Inquiry to be held into Nottingham attacks
A public inquiry is to be held to examine the events which led to Valdo Calocane stabbing three people to death in Nottingham in June last year, the families of his victims have said.
A statement from their families revealed they have had confirmation that a public inquiry will take place, after meeting Health Secretary Wes Streeting and Attorney General Richard Hermer.
It said: "Following meetings with the Attorney General and Health Secretary on Tuesday of last week, we are pleased to have had confirmation that a public inquiry will take place.
"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
CQC report finds opportunities missed by Nottinghamshire's health services
The news of a public inquiry comes after the final part of a special Care Quality Commission (CQC) 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 also questioned how well the trust engaged with Calocane's family, who raised concerns about his mental state.
Chris Dzikiti, interim chief inspector of healthcare at the CQC, said: "This review identifies points where poor decision-making, omissions and errors of judgments contributed to a situation where a patient with very serious mental health issues did not receive the support and follow-up he needed.
"While it is not possible to say that the devastating events of June 13 2023 would not have taken place had Valdo Calocane received that support, what is clear is that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed."
The CQC said Calocane had "little understanding or acceptance of his condition" which could "have significantly impaired his ability" to weigh up the pros and cons of antipsychotic treatment and the risks of discontinuing it.
It would have been possible to treat him under section 3 of the Mental Health Act (MHA) 1983 - which would have given doctors the power to administer drugs against his will - on his fourth admission to hospital in January 2022, the regulator said.
Instead, he was treated under section 2 of the act, which is usually for patients who are not known to mental health services.
CQC recommendations after the Nottingham attacks
Among its recommendations, the CQC said NHFT should review treatment plans for people with schizophrenia regularly, as well as ensuring clinical supervision of decisions to detain people under section 2 and 3 of the Mental Health Act.
It also called for NHS England to publish guidance setting out national standards for care for people with complex psychosis and paranoid schizophrenia in the next 12 months.
Nottinghamshire health care apologises
Nottinghamshire Healthcare Chief Executive, Ifti Majid said: “I offer our sincere apologies to the families of Grace, Ian and Barnaby who lost their lives and to Wayne, Sharon and Marcion who were seriously injured. Clearly, today is another reminder of the tragic events of last June, and our thoughts are with all those whose lives changed irreparably after the attacks.
“We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out. Our teams have much more contact with people waiting to be seen in the community to agree crisis plans and ensure they have an up-to-date risk assessment even when they are struggling to engage with our services or primary care.
“Colleagues are also working to improve alignment between our teams, primary care and talking therapies, helping to reduce waiting times as well as communicate more effectively when patients move between services or disengage from treatment.
“We have a clear plan to address the issues highlighted and are doing everything in our power to understand where we missed opportunities and learn from them.”
Health Secretary wants lessons to be learned
Health Secretary Wes Streeting, said: "I want to assure myself and the country that the failures identified in Nottinghamshire are not being repeated elsewhere.
"I expect the findings and recommendations in this report to be considered and applied throughout the country so that other families do not experience the unimaginable pain that Barnaby, Grace and Ian's family are living with."
The families' statement added: "Progress is slowly being made and we will continue in our fight to ensure there is full organisational and individual accountability for the horrific events of 13 June 2023.
"We will also fight to ensure that appropriate changes and improvements to our systems and laws are made so as to ensure that a tragedy of this level is prevented from ever happening again."
Calocane's brother Elias echoed calls from the victims' relatives for a public inquiry earlier this week.
"We need some strong recommendations," he told the BBC's Panorama programme.
"But we can't just say we'll just wait until it finishes how many years down the line and then do something about it then. Something needs to happen now."
Warnings Calocane could kill three years before attacks
It also emerged that a psychiatrist warned Calocane could "end up killing someone" three years before the attacks in June 2023.
His family told Panorama they only received the 300-page medical summary containing the warning after his sentencing.
Calocane was handed an indefinite hospital order in January after admitting manslaughter on the grounds of diminished responsibility.
Prosecutors accepted his not-guilty pleas to murder after multiple medical experts concluded he had paranoid schizophrenia.