In June 2023, Valdo Calocane fatally stabbed students Barnaby Webber and Grace O’Malley-Kumar, as well as carer Ian Coates. According to a review, risk assessments conducted prior to the killings downplayed the fact that he refused to take medication and was experiencing ongoing and persistent psychotic symptoms.
Services that cared for Nottingham killer Valdo Calocane prior to his attacks have been accused of having “blood on their hands” after it was revealed that an NHS trust “minimised or omitted” vital evidence about the considerable risk he presented to others.
Calocane, who has delusional schizophrenia, stabbed 19-year-old students Barnaby Webber and Grace O’Malley-Kumar before killing 65-year-old caretaker Ian Coates in June 2023.
In January, he was confined to a high-security hospital, likely for the remainder of his life, after prosecutors accepted a manslaughter plea with reduced culpability.
The Care Quality Commission (CQC) reviewed how Nottinghamshire Healthcare NHS Foundation Trust (NHFT) cared for 32-year-old Calocane prior to the killings.
It was discovered that from May 2020 until September 2022, the trust’s risk assessments downplayed the fact that Calocane refused to take his medication and was experiencing ongoing and persistent signs of psychosis.
While some hazards were noted, the agency stated that other assessments “minimised or omitted key details.”.
It was noted that a decision to discharge the attacker back to his GP in 2022 was taken despite clear evidence that Calocane would “relapse into distressing symptoms and potentially aggressive behaviour.”.
Calocane was also reported to have been hospitalised four times before the attacks due to mental health issues.
Grace’s parents, Dr. Sinead O’Malley and Dr. Sanjoy Kumar, told Sky News they were “devastated” by the revelation.
Dr. Kumar went on to say, “We had a basic example of a guilty person who failed to take his prescription.
“All of this is heartbreaking to read. It was quite simple.
“The errors were not technical; they were simple, basic errors… There were numerous possibilities to change Calocane’s fate, but none of the doctors took advantage of them.
“The doctor who actually discharged him—that was the most irresponsible thing to do knowing that… a doctor had put in the notes he had the potential to murder someone.”
He went further: “Any psychiatrist that puts a dangerous person on our streets has to be held responsible for putting that patient out.”
According to the CQC, there appeared to be “a series of errors, omissions, and misjudgments” in Calocane’s care.
Chris Dzikiti, the watchdog’s interim chief inspector of healthcare, stated: “This review identifies points where poor decision-making, omissions, and errors of judgement contributed to a situation in which a patient with very serious mental health issues did not receive the support and follow-up he required.”
He stated that while it is impossible to conclude that the events of June last year would not have occurred if Calocane had received the necessary support, it is apparent “that the risk he presented to the public was not managed well and that opportunities to mitigate that risk were missed”.
“For the individuals involved, their families, and loved ones, the damage cannot be undone,” Mr. Dzikiti continued.
When Calocane’s family expressed concerns about his mental health on multiple occasions, the Care Quality Commission (CQC) questioned the trust’s ability to communicate effectively with them.
“Devastating reading” is what the families of the victims described the conclusions of the review as being.
“This report demonstrates gross, systemic failures in the mental health trust in their dealings with Calocane, from beginning to end,” they stated in a statement that they jointly issued.
We were let down by a number of organisations both before and after the month of June 2023. All of these departments and individual experts, in addition to the police forces of Leicestershire and Nottinghamshire, have blood on their hands.
Within the mental health trust, it appears that there is either very little or no responsibility within the senior management team. This is a very concerning situation. To what extent and for what reasons are these individuals still in their positions?
Following a meeting with Health Secretary Wes Streeting and Attorney General Richard Hermer, the families acknowledged that a public investigation will be held to investigate the events leading up to the attack.
Following Calocane’s conviction, then-Health Secretary Victoria Atkins requested a special review of NHFT’s mental health services in January.
According to the CQC’s conclusions issued on Tuesday, it was “clear that Calocane was acutely unwell” from the time he was in the trust’s care.
He displayed psychotic characteristics, appeared to have little knowledge or acceptance of his condition, and had problems taking his medicine from the start, according to the CQC.
The CQC also determined that if Calocane had been treated under Section 3 of the Mental Health Act following his fourth hospital admission, healthcare professionals could have administered longer-term medication, even against his will, or considered placing him under a community treatment order, which allows treatment to take place in the community rather than in a hospital.
Calocane was instead classified under Section 2 of the legislation, which is normally reserved for people who are unfamiliar with mental health services.
Mr. Streeting stated that the investigation “makes for distressing reading, especially for those living with the consequences of their loss in the knowledge that their untimely deaths were avoidable” .
“I want to assure myself and the country that the failures identified in Nottinghamshire are not being repeated elsewhere,” he said later.
A spokeswoman for the NHFT responded: “We acknowledge and accept the conclusions of this report and have significantly improved processes and standards since the review was carried out.”
The Calocane case sparked outrage and resulted in multiple investigations into the public bodies involved, including Nottinghamshire and Leicestershire Police.